The dissertation is devoted to the problem of combat trauma of the abdomen and pelvis, in particular the diagnosis, assessment of severity and surgical treatment of injuries of the bladder and posterior urethra.
Among the studied clinical observations, we included injuries of the bladder and posterior urethra in injuries of the abdomen and pelvis caused by combat surgical trauma, as well as victims with the same injuries received in peacetime.
115 patients with bladder and posterior urethral injuries were analyzed. Two clinical comparison groups were formed: the main – 54 wounded in combat, the comparison group – 61 victims with injuries of the bladder and posterior urethra in peacetime. The main group used a modified scale for assessing the severity of injury, improved organizational and tactical scheme of diagnosis and provision of surgical care using the principles of DCS (damage-control surgery). In the comparison group, care was provided in accordance with current clinical protocols in peacetime.
The bladder was damaged in 38.9 % in the main group and 39.3 % in the comparison group, the posterior urethra in 12.9 % and 9.8 % of cases, a combination of injuries of the bladder and posterior urethra, including complete separation of the urethra from the bladder was 48.2 % and 50.8 % of cases, respectively.
Gunshot wounds were the leading mechanism for injury in the main group (74 %). In the comparison group, the reasons were: traffic accidents in 40.9 %
of cases, catatrauma in 26.2 %, others – 32.8 % of cases. The main mechanism of injury was compression-distraction 27.9 % and falling from a height of 22.9 %.
Traumatic shock was observed in 94.4 % of the main and 91.2 % of the comparison group. The injured were more likely to be in traumatic shock of the third degree – 48.2 % in the main group and 44.2 % in the comparison group. Traumatic shock of the IV degree – at 25,9 % and 21,3 % accordingly.
Assessment of the severity of trauma on admission in the main group was performed on a scale – AdTS (Admission trauma scale), which allows for medical sorting and determine surgical tactics. Mild injury was observed in 12.9 %, severe – in 51.9 %, extremely severe – in 35.2 % of cases in the main group.
The severity of the injury in the comparison groups was determined by the ATS scale (Anatomic trauma score). Mild injury was observed in 14.8 % and 16.4 %, severe – in 48.1 % and 52.5 %, extremely severe – in 37.1 and 31.1 %, respectively.
The severity of the injury in the comparison groups was determined by the ATS scale (Anatomic trauma score). Mild injury was observed in 14.8 % and 16.4 %, severe – in 48.1 % and 52.5 %, extremely severe – in 37.1 and 31.1 %, respectively. At the second level, the wounded with non-severe trauma (n = 8) underwent ultrasound examination according to the FAST protocol, pelvic radiography – 62.5 %, Zeldovich test in 100 %, ascending ureterocystography in 50 %. The duration of diagnosis was 46.4 minutes.
At the III and IV levels, diagnostic possibilities were expanded by performing excretory urography, computed tomography or magnetic resonance imaging, primarily for the diagnosis of complications. In the comparison group, diagnostic measures were performed at the hospital stage according to unified study protocols.
Surgical tactics in the main group depended on the severity of the injury.
In non-severe trauma, a full range of surgical manipulations was performed, in severe trauma – reduced, and in extremely severe trauma (n = 20) DCS (damage control surgery) tactics were used. In the first phase, hemostasis and decontamination, urination and intraoperative prevention of complications were monitored. In the second phase, measures were taken to stabilize the condition of the wounded (35.2 %), medical evacuation was carried out (20.4 %). The third phase included the implementation of the full range of operations, which were performed in 14.8 %
of cases at the second level and in 20.4 % at the third level.
There was an increase in the proportion of complications of the clinical course in the main group: early by 3.6 % and late by 8.6 %.
Comparative analysis showed that mortality at 1 and 2 days in the main group was lower by 5.3 %, which is due to the use of DCS tactics for extremely severe injuries. The main causes of death were traumatic shock and blood loss.
Mortality in the period of early manifestations of TD did not differ significantly, the cause of death was multiple organ failure and thromboembolic complications, and in subsequent periods - purulent-septic complications and traumatic exhaustion.
