Stupnytskyi M. The pathophysiological mechanisms and the complications risk criteria of combined thoracic trauma

The thesis presents results of the study about the role and importance of basic pathophysiological mechanisms involved in the pathogenesis of the combined thoracic trauma (CTT) during early posttraumatic period. The main pathogenesis feature of this type of trauma is the presence of many limiting factors. They determine the criteria of decompensation of the wound dystrophy (WD). Also there is relative burden due to the presence of combined injuries of the several organs and systems. It was proved that the combination of thoracic trauma with the severe traumatic brain injury significantly worsens outcome. Patients with combination of the severe thoracic trauma injuries (3 and 4 points according to AIS) with severe and critical head injuries (4 and 5 AIS points) should be classified into the high risk group. Target hemoglobin level was established and statistically grounded on the 1-2nd day after the severe CTT. It is determined as 104 (100 - 106) g/L, and can serve as additional indication for transfusion. Derangement of the trace elements metabolism is characterized by their reduced concentrations in blood plasma due to blood loss. The transferrin saturation and copper/ ceruloplasmin ratio are decreased. Zinc/albumin ratio increases in plasma due to the bones trauma. Low copper concentration, copper/ceruloplasmin ratio and transferrin saturation were observed in patients' plasma with unfavorable outcome owing to the impossibility of valid enteral nutrition. First was found influence of infusion therapy on the absolute concentrations of malondialdehyde (MDA) and carbonyl groups of proteins (CGP). Favorable outcome of WD can be expected in case of the MDA levels on the 1-2nd day ranged from 0.1023 to 0.1448 mmol/g of protein combined with the concentration of the CGP ranged from 14.14 to 17.46 mmol/g of protein and doubtful outcome with the range from 10.77 to 14.14 mmol/g protein. Very high and very low concentrations of MDA and CGP are statistically significant prognostic signs of adverse outcome. Hypoproteinemia and hypoalbuminemia are prevalent on the 1-2nd day after injury as the result of blood loss combined with the activation of autoaggression mechanisms in response to tissue damage discovering as increasing of the y-globulins concentration. In the sequel, the mechanisms of WD compensation are gaining in the most importance discovering as activation of the a1-globulins synthesis. Predictive criteria were established according to the concentration of albumin for the 1-2nd day and a1-globulins for the 3-4th and for the 5-6th days of post-traumatic period. The association between the level of traumatic shock and concentrations of the acute phase proteins (haptoglobin and ceruloplasmin) on the 1-2nd day after trauma was revealed for the first time. The decrease of ceruloplasmin concentration <266,2 mg/L and haptoglobin <856,5 mg/L confirms severe traumatic shock (II or III degree). The development of the immune system autoaggression of the CTT patients was confirmed, manifested by recruitment of the immature neutrophils and by cytokines imbalance with domination of proinflammatory mediators during the first 5-6 days after a trauma. The syndrome of endogenous intoxication develops early on the 1-2nd day after trauma. Its intensity is proportional to the severity of the mechanical injury and traumatic shock. The severity of endogenous intoxication decreases to the 5-6th day in survivors, and on the contrary is gradually growing in nonsurvivors. The injury severity can be estimated on the 1-2nd day after trauma based on the concentrations of MDA and CGP, acute phase proteins ceruloplasmin and haptoglobin, albumin, y-globulins, and the zinc/albumin ratio. Interleukin-10, a1-globulins, stab neutrophils and aromatic fractions of middle mass molecules receives significant prognostic value on the 3-4th day. Statistically objective criteria for the high risk group at the 5-6th day are low percentage of а1-globulins, increased concentrations of CGP, middle mass molecules, the percentage of в-globulins, and reduced percentage of monocytes. The analysis of studied relationships allowed developing of predictive model for evaluating the severity of the homeostasis disturbances in the case of WD. The scheme of the WD progression was established according to it. The most significant contribution on the 1-2nd day of the early post-traumatic period makes pathophysiological mechanisms associated with blood loss - the decrease of albumin and transferrin concentrations, then toxic iron release due to hematomas lysis, respiratory dysfunction and the development of systemic inflammatory response syndrome. Mechanisms of "unstable adaptation" were defined as the most dominant for the 3-4th day after trauma. The key role belongs to deficiency of а1-globulins and imbalance of the proinflammatory/anti-inflammatory interleukins which determines the finalizing of autoaggression with transition into anti-infective functioning of the immune system. The 5-6th day of CTT is characterizing as the final formation of the prolonged adaptation mechanisms. The а1-globulins concentration does not lose its crucial value. The mechanisms of the oxygen uptake disturbance and oxidative stress are involved in decompensation of WD.