The review deals with modern methods of assessing the severity and predicting the outcome of polytrauma. To solve the problem of objective evaluation of polytrauma severity, numerous studies are devoted to the search for independent predictors of its outcome, many of which are included in various scales and statistical models to quantitatively rank the severity of injury in the established intervals and calculate the survival probability. It is generally accepted to take into account the anatomical criteria to determine the severity of damage, and physiological parameters that characterize the response of the body functional systems to the damage. Age, sex, comorbidities, various clinical parameters, indices of acidosis, coagulopathy, oxidative stress, inflammatory response, timely diagnosing and the quality of treatment, the need of rendering various types of emergency aid are considered as independent risk factors of fatal polytrauma outcome.The predictive value and comparative effectiveness used in polytrauma scales assessing the severity of injuries (ISS, NISS, APS, ICISS, TMPM) and functional disorders (GCS, RTS, APACHE II, MODS II, SOFA, SAPS II, MPM II) as well as a variety of combined clinical and anatomical evaluation systems (TRISS, ASCOT, RISC II, PTS, etc.) are being actively discussed in the modern literature. Creating a universal scale is complicated by a variety of damages and disorders caused by a polytrauma, and insufficient study of injury outcome predictors. The proposed survival rates and prognostic factors are tied to specific polytrauma databases differing in terms of mortality and quality of medical care, which is reflected in their predictive value.A clear definition of polytrauma and formation of a unified system of assessing its severity would allow physicians to standardize treatment policy, objectively solve the problems of organization and financial support of medical help to seriously injured people.Key words: polytrauma; prognostic factors in polytrauma; mortality in polytrauma; scales and systems of injury severity evaluation.For contacts: Pavel A. Seliverstov,
INTRODUCTION. Splenic injuries in abdominal trauma is one of the most common injuries in abdominal surgery. The damage to this organ occurs in 22.3–30%. This is the second most common injury among damages to parenchymal organs.AIM OF STUDY. To study the immediate results of treatment and to determine the factors that influence the choice of tactics for open injuries of the spleen.MATERIALS AND METHODS. The study included 75 patients with abdominal wound and damaged spleen. In 54 (72%) patients, stab and slash wounds were revealed, in 21 (28%) patients there were gunshot wounds (bullet or fragment). All patients were divided into two groups: Group A included 44 (58.6%) of patients, where the time gap between the time of injury and the surgery did not exceed 1 hour, and Group B, which included 31 (41.3 %) of cases, where the time gap between the moment of injury and surgical intervention exceeded 1 hour.RESULTS. As a result of the study, it was found that organ-preserving operations for open injuries of the spleen were possible in 33.3% of cases. The choice of surgical tactics for injuries of this organ depended on the type of damage to the organ: in case of gunshot wounds of the spleen, the organ-preserving operation was not possible at all, but this operation was performed for stab/slash wounds in 33.3% of cases. The development of complications and deaths directly depended on the journey time: in the case of that time gap up to one hour, complications developed in 27.3% of cases, and the mortality rate was 15.9%. If the time of journey exceeded 1 hour, the number of complications increased to 77.4%, and mortality rate grew up to 51.6%. According to our data, the number of complications and deaths depended more on the time of admission than on the type of operation performed. In addition, it is necessary to note one more factor that affected the lethal outcome and this was the type of the wound. Therefore, as a result of the study, it was found that mortality in the group with gunshot wounds amounted to 17 out of 21 (80.95%), and for stab/slash wounds it was 6 out of 54 (11.1%). It was found that the journey time and the type of operation performed operation affected the level of D-dimer in patients with splenic injuries. So, the level of D-dimer was 566±0.3 ng/ml in the group of the wounded, delivered within an hour after trauma, and 643±0.2 ng/ml in the group where the journey time exceeded an hour.CONCLUSIONS. 1. Performing organ-preserving operations with open injuries of the spleen is possible in 46.3% of cases and only for stab and slash wounds. Organ-preserving operations cannot be performed for gunshot wounds.2. The number of complications and deaths is more dependent on the journey time to the hospital than on the type of operation performed. If a patient is admitted within an hour after trauma, the complication rate is 27.3%, and mortality rate is 15.9%. If the journey time exceeds one hour, the complication rate is 77.4% and the mortality rate is 51.6%.3. In patients splenic inguries, the journey time and the type of the operation performed affect the level of the D-dimer, which may affect the course of the immediate postoperative period.
In case of poly-trauma the early operations of osteosynthesis under fractures of long bones, unstable fractures of pelvis and backbone bones being an operational trauma, can provoke progression of inflammatory reaction, development of systemic complications and poly-organ inadequacy i.e. causing a «second hit» effect. The pathophysiologic mechanisms of «second hit» phenomenon are complicated and they are implementing by means of modulation of immune response. The risk of development of the given phenomenon depends on period of implementation and method of osteosynthesis, severity of injuries and condition, age, concomitant pathology of patient, presence of chest trauma and craniocerebral trauma. The study of pathophysiology of «second hit» phenomenon is perspective for development and optimization of clinical concepts of treatment of patients with poly-trauma and skeletal damages.
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