Good clinical practice of initial management of intensive care following combat and civilized multitrauma (literature review)

І.А. Iovenko, Yu.Yu. Kobelyatskyу, A.V. Tsarev, E.A. Kuzmova, L.L. Dubovskaya, V.Y. Mynka, U.V. Seleznyova

Abstract


The literature review presents the modern views on the initial management of intensive care of multitrauma. It is substantiated the importance of identifying risk factors and prevailing traumatic injuries to select the composition and vo­lume of infusion therapy on the base of the trauma characteristics and the clinical situation (head injury, penetrating or blunt trauma, continued bleeding, compartment syndrome). The paper shows the necessity of the massive bleeding protocol in the case of massive blood loss with prediction of the expected blood loss, risk assessment and severity of coagulopathy. It is focused on the need for early introduction of blood products in the ratio of red blood cells : FFP : platelet as 1 : 1 : 1 or 1 : 1 : 2. The paper describes the advantages, disadvantages and potential risks of the use of different crystalloid and colloid plasma substitutes. The key task of infusion therapy is to ensure tissue perfusion, and adequate oxygen delivery and its consumption, considering danger of hypovolemia and extreme hemodilution, tissue edema and organ dysfunction. Balanced crystalloid solutions are recommended as drugs of choice in most cases, but synthetic colloids may be necessary to maintain life support during long distance transport to the hospital in the absence of blood products. The article presents the strategic objectives, target endpoints and the recommended variants of infusion therapy monitoring in patients with multitrauma. The assessment of blood coagulation should be carried out by available methods (PTI, APTT, INR, fibrinogen and platelets) with a preference for viscoelastic methods (thromboelastography). Ultrasonic methods of evaluating cardiovascular function (cardiac output) in real time are recommended to correlate with other clinical parameters. A combination of dynamic assessment of aortic flow with passive legraising (PLR) test is preferred. In the absence of ultrasound methods, dynamic parameters, such as passive leg raising (PLR) test must be used, although they may have limited utility in an emergency cases. If it is impossible to use ultrasound test or passive leg raising test, you can use other dynamic markers, although they may be impractical in an emergency. Evaluation of the patient’s response to repeated boluses of intravenous fluid (100–250 ml) can be used with caution in relation to the risk of fluid overload. The paper described the specific clinical situations (children, elderly patients, pregnant women, burn injury, rhabdomyolysis), and some issues of damage control surgery and its role in intensive care of severe multitrauma.


Keywords


multitrauma; massive bleeding; coagulopathy; infusion therapy; blood transfusion; monitoring; intensive care; review

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DOI: https://doi.org/10.22141/2224-0586.2.81.2017.99691

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