The dissertation is devoted to the problems of surgical treatment of victims with chest trauma accompanied by flail chest.
The study was built using a comparative analysis of the results of diagnosis, clinical course, assessment of severity, surgical tactics and treatment of two groups of patients with flail chest.
The first group (the main group, 56 patients) is the victims who underwent operations to stabilize the floating segments of the chest. The second group (comparison, 67 patients) are victims who underwent conservative treatment. The total sample of the study was 123 patients.
The criteria for inclusion in the study were: the presence of a thoracic injury with flail chest (fractures of three or more ribs along two or more lines); absence of severe TBI (severe cerebral contusion, diffuse axonal damage); predominance of the thoracic component in combined trauma; duration of treatment over 2 days.
Exclusion criteria were: extremely severe injury with IV degree traumatic shock; mortality during the acute period of a traumatic illness (up to 48 hours); severe brain injury.
In terms of age, sex, severity of injury, nature and mechanism of injury, type of instability, degree of traumatic shock, presence of intrapleural complications and damage to other anatomical and functional areas, the study groups were homogeneous and had no statistical differences.
Study groups were compared for injury severity at admission based on the ATS anatomical scale. The main group was additionally evaluated according to the AdTS scale and the perfusion index was determined to objectively assess the severity of the injury. Correlation analysis revealed a strong direct relationship (r=0.95) between the degree of shock and the score on the AdTS scale and a strong inverse relationship between the severity of the injury and the perfusion index (r=0.94).
Instrumental and intraoperative methods played a leading role in the diagnosis of instability of the sterno-costal framework and complications of trauma.
On the basis of an objective assessment of the severity of the injury in the main group, a differentiated diagnostic program was developed, which determined the scope, place and order of diagnostic measures. Thus, in the case of a mild injury, the entire complex of diagnostic examinations was performed in the conditions of the reception department; in case of severe injury - reduced, in the conditions of an anti-shock ward; in extremely severe cases - the minimum volume in the operating room. The developed differentiated diagnostic program made it possible to reduce the time of preoperative examination in severe and extremely severe trauma by 2.4±0.1 min and 9.8±1.2 min, respectively (p<0.001).
Laboratory, instrumental and functional methods were used to monitor the course of the traumatic disease.
Based on the determination of the severity of the injury in the patients of the main group, a decision was made regarding surgical tactics. In the comparison group, surgical tactics were evaluated based on the study of disease histories.
In order to prevent the development of complications associated with long-term ventilation through an endotracheal tube, patients in the main group underwent early tracheostomy formation (2.7±0.6 days). In the patients of the comparison group, tracheostomies were formed later (5.5±1.1 days). Unlike the patients of the comparison group, all severe and extremely severe patients of the main group had to undergo bronchoscopy in 1-2 days.
The choice of terms of surgery and methods of stabilization had an individual approach. In the case of a mild injury, stabilization of the floating segments was performed by all available methods. Preference was given to delayed interventions under video thoracoscopic control. In case of severe trauma, operations on the chest were performed after the patients were brought out of shock. In the presence of intrapleural complications that required surgical correction, stabilization was performed during thoracotomy or video-assisted.
In the absence of intrapleural complications, preference was given to extrapleural methods of fixation. In case of an extremely severe injury, the stabilization of the floating segments was carried out with spokes during the 1st phase of DCS during thoracotomy or by extrapleural methods during the 3rd phase of DCS. The method of operation was chosen on the basis of the developed classification.
The assessment of the severity of the injury was the basis for determining the diagnostic program, surgical tactics, timing of surgery on chest and the technique of stabilizing the floating segments.
