Tactics of providing medical care to victims with injuries of the urinary system as a result of road traffic accidents of the urinary system
- Authors: arzhanykh Y.v., zolotukhin v.o.
- Issue: Vol 9 (2020): Материалы XVI Международной Бурденковской научной конференции 23-25 апреля 2020 года
- Pages: 401-402
- Section: Хирургические дисциплины
- URL: https://new.vestnik-surgery.com/index.php/2415-7805/article/view/5949
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Abstract
Relevance. Damage to the bones and organs of the small pelvis is the most difficult type of combined injury [1]. The overwhelming majority (87-94%) is the result of road traffic injuries [2]. Surgical care for victims of this category should be multidisciplinary and provided in a specialized medical institution with a specialized trauma department.
Purpose. To analyze the types of injuries received and the features of providing optimal specialized medical care to victims of road accidents. Assess the effectiveness of the treatment.
Methods. We studied 34 case histories of patients with severe injuries of the pelvic bones and urinary tract organs who received treatment at BUZ VOKB No. 1 from December 2018 to November 2019. Based on the results of the data analysis, conclusions and conclusions are drawn.
Results. The combined nature of the trauma resulting from an accident requires a strict sequence of actions from surgeons in the provision of emergency surgical care in a hospital setting. In the presence of chest injuries or abdominal trauma, a thoracoabdominal operation was performed - drainage of the pleural cavity for hemopneumothorax or midline laparotomy for hemoperitoneum. Then the application of the external fixation rod (ANF) was started. After that, operations were performed for intracranial hematomas.
Suturing of the bladder wound, the imposition of an epicystostomy, and drainage of pelvic tissue were performed in all patients with injuries of the lower urinary tract.
With a ruptured urethra, removal of the epicystostomy is mandatory surgical manipulation.
Conclusion. When providing emergency surgical care, first of all, we recommend thoracoabdominal surgery. In the presence of traumatic brain injury, perform decompression craniotomy in order to remove intracranial hematomas. For open fractures of the limb bones after primary surgical treatment, it is necessary to immobilize with an external fixation device. Stabilize the pelvic bones by imposing a core ANF.
Key words: road accident; damage; urinary tract; trauma to the pelvic organs
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Relevance. In 2019, more than 2,000 road accidents were registered in the Voronezh region, which is 20% more than in 2018, while more than 250 people died and more than 2,500 were injured in various
severity [3]. Injuries to the organs and bones of the pelvis are the most dangerous and serious injuries. The mortality rate of these injuries is up to 46% and in some cases may be accompanied by life-threatening complications. Most often, these injuries occur in road traffic accidents [4]. When providing assistance to victims of road traffic accidents, many diagnostic and therapeutic problems arise, which requires consultation and participation of doctors of various specialties, namely, vascular surgeons, urologists, traumatologists. Therefore, surgical care for injuries to the bones and pelvic organs should be multidisciplinary.
Purpose of the study. Identify the most typical types of damage that occur as a result of road accidents. To develop the optimal tactics for providing emergency surgical care to victims of road accidents. Assess the effectiveness of the treatment.
Materials and methods. We performed a retrospective analysis of 36 case histories of patients with concomitant trauma, including fractures of the pelvic bones and injuries of the urinary organs. Treatment was carried out on the basis of BUZ VOKB No. 1 in Voronezh from December 2018 to November 2019.
34 victims (94.4%) were taken to hospital with injuries resulting from an accident; 2 people (5.6%) were delivered with injuries received through negligence.
As a result of the study, it was revealed that rupture of the kidney was observed in 1 victim (2.94%). Bladder injuries were diagnosed in 26 people (76.4%), among whom 9 patients (20.5%) had intraperitoneal bladder ruptures, and 18 patients (50%) had extraperitoneal ruptures. Injury to the inner part of the vagina was observed in 1 patient (2.94%), rupture of the urethra in 3 men (8.82%).
The most common among injuries of the pelvic bones was a combined injury to the pelvic ring - 17 people (50 %) ( 32.3%). Damage to the posterior half-ring was caused by ruptures of the sacroiliac joint - 6 people (20%).
A concomitant injury resulting from an accident is also characterized by extra-pelvic injuries: traumatic brain injury with intracranial hematoma in 2 victims (5.88%), closed trauma of the abdominal organs - 3 victims (9.3%), closed chest injury in 20 (58 , 8%), closed limb fractures in 26 (81.2%), open limb fractures with massive bleeding were observed in 7 patients (21.8%).
X-ray, ultrasound and computed tomography were used to diagnose kidney damage. Retrograde cystography was used to diagnose bladder injuries, and urethral injuries were studied using ascending urethrography .
Results.
All victims at the prehospital stage of medical care were treated with non-narcotic (intravenous administration of ketarol , 1% Novocaine solution) and narcotic (intravenous promedol , morphine, tramadol ) analgesics, infusion therapy in cases of acute blood loss or traumatic shock, transport immobilization with Kramer and Dieterichs splints in case of limb fractures, in case of fracture of the pelvic bones on a rigid shield with the "frog" pose, head immobilization was carried out using a cotton gauze circle and evacuation to health care facilities. In varying volumes, this assistance was provided to the majority of the injured 32 patients (94%). 4 patients (6%) went to a medical facility on their own within the first hour after the accident. There were no violations in the transportation of patients.
The combined nature of the trauma resulting from an accident requires a strict sequence of actions from surgeons in the provision of emergency surgical care in a hospital setting.
Thoracoabdominal surgery was performed in the presence of chest injuries or abdominal trauma. 55.6% of the victims (20 operations) were performed for hemopneumatorox - drainage of the pleural cavity, as well as midline laparotomy for the treatment of hemoperitoneum - 3 operations (8.3%).
Then they proceeded to immobilization using an external fixation rod (ANF) to stabilize the pelvis. This operation was performed on 34 victims.
Operations on the background of intracranial hematomas ( decompressive craniotomy) were performed in 2 victims (5.6%).
Osteosynthesis of closed limb bone fractures was performed in 26 victims ( 72.2%).
Kidney ruptures were diagnosed and sutured on the day of admission 1 operation (2.8%). Vaginal wounds were sutured on the first day of 1 operation (2.8%).
Surgical treatment for extraperitoneal bladder ruptures was provided to 17 patients, which included extraperitoneal access, revision, suturing of the bladder wall with a 2-row suture.
For intraperitoneal bladder ruptures, 9 operations (25%) included laparotomy, revision of the abdominal cavity, suturing of the bladder, and epicystostomy .
Discussion.
The overall mortality rate among victims of road traffic accidents was 11.76% (4 patients). The causes of death in 3 cases were shock and acute blood loss against the background of severe concomitant trauma during the first day. In one case, the cause of death was sepsis (death on the 8th day).
In 30 surviving patients, infectious complications were detected in 14 cases (46.6%). All 3 patients with urethral rupture were discharged with an epicystostomy catheter for reconstructive plastic surgery.
Rehabilitation of patients began immediately after the end of the surgery. Classes with patients were structured according to the following scheme: from the 1st or 2nd day, therapeutic gymnastics began with a gradual and gradual increase in physical activity. From the 3-4th day, the physical activity was expanded with the addition of active alternating and simultaneous movements in the joints of the lower limb. From 2 days after the start of therapeutic exercises, mechanotherapy was started using the RECK MOTOmed letto2 simulator and electrical stimulation.
Conclusion
1. Successful treatment of victims of road traffic accidents with pelvic injuries is possible only in a specialized medical institution with a specialized trauma department.
2. To exclude the formation of purulent-necrotic complications, the formation of urohematoma, it is necessary to choose the correct treatment tactics. To avoid the development of osteomyelitis of the damaged segment at the initial stage, fixation of bone fragments with an external fixation device is mandatory. After the performed antibiotic therapy and stabilization of the general condition of the patient, it is possible to switch to external osteosynthesis.
3. Applying an external fixation device to the damaged pelvic ring helps to reduce pelvic pressure, self-tamponade of damaged vessels and prevent bleeding into the retroperitoneal space.
Thus, in the provision of emergency surgical care, first of all, we recommend thoracoabdominal surgery. In the presence of traumatic brain injury, perform decompression craniotomy in order to remove intracranial hematomas. For open fractures of the limb bones after
during the primary surgical treatment, it is necessary to perform immobilization with an external fixation device. Stabilize the pelvic bones by applying a core ANF.
About the authors
Yana vyacheslavovna arzhanykh
Email: yana.arzhanyh@yandex.ru
ORCID iD: 0000-0001-9064-0623
vladimir olegovich zolotukhin
Author for correspondence.
Email: vladimir.zolotuxin@gmail.com
ORCID iD: 0000-0002-8513-3966
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