[Methodological aspects of surgical approach in victims with severe multiple craniofacial trauma in consideration of severity of traumatic injury].

It is important to improve the medical care system and treatment of victims, introduce new methods of treatment and attract the multidisciplinary specialists in the cases of multitrauma. An integrated approach is required for the identification of different character and severity of multiple craniofacial injuries and the development of rational surgical strategy on this base. Different scales such as AIS, CRIS, ISS, PTS, TRISS, TRISSCAN, CRAMS et.al, were created abroad. Another approach to medical strategy was developed in the department of military surgery of Kirov Military Academy in the late nineties. It was based on investigating of possibilities of surgical strategy optimization by application of objective evaluation of the severity of injuries (military surgery--SP, SG, SS). Given treatment strategy of victims with multiple craniofacial trauma resulted in double reduction of quantity of suppurative and septic complications (from 10.5% to 4.1%). It gave the possibility to reduce the lethality from 6.4% to 4.0%. At the same time a hospital stay was shortened and the strategy allowed obtaining satisfactory functional results of treatment and avoiding reinterventions for removal of posttraumatic facial deformations.

[Ways of improving of intensive care for victims with severe concomitant injury].

In terms of prognosis of the outcome of traumatic disease as a disease of adaptation particularly significant is a functional component. Updating of options of the course of traumatic disease allow to combine two principles of intensive care such as individual focus and standardization. Innovations of recent years, embedded into the battlefield surgery clinic of Military Medical Academy n. a. S.M.Kirov in tactics and content of intensive care, improved the current situation on the results of treatment of patients with polytrauma.

[Tracheostomy in the process of prolonged artificial pulmonary ventilation in patients with polytrauma].

One of modern tendencies of carrying out long ALV of patients with polytrauma is application of "early" tracheostomy. Thus optimum terms of early tracheostomy are defined indistinctly and vary from 2 to 10 days from beginning of ALV. It is established that at predicted long ALV of patients with polytrauma optimum terms of tracheostomy performance is the second period of traumatic illness (12-48 hours from the moment of getting trauma). Tracheostomy, executed for patients with polytrauma for the purpose of maintenance long AL V in early terms, promotes improvement of gases diffusion, microcirculation in lungs, improvement of system of external breath as a whole and it is accompanied by decrease in frequency of development life danger infectious pulmonary complications and lethality reduction.

["Low infusion resuscitation" in the treatment of wounded and injured with acute massive blood loss].

Acute massive blood loss (AMBL) of severe and extremely severe degree is still one of the leading causes of unfavourable traumatic disease. 95% of potentially preventable lethal outcomes in severe gunshot trauma is reported to depend largely on the adequacy of AMBL correction (Howard P., 2003). An alternate approach to the issue studied was the development of preparations of hyperosmotic saline solutions (7.5% sodium chloride) combined with hyperoncotic colloid solutions (dextrans, hetastarch). As a result, solutions were developed (so-called, hyperosmotic hyperoncotic volume expanders) allowing to achieve rapid and stable volemic and hemodynamic effect in case of low volume infusion (usually, 4 ml/kg of body weight). The present study allowed to conclude that "low infusion resuscitation" technique in patients with multiple trauma accompanied by acute massive blood loss of extremely severe degree enables to reduce lethality, to achieve early subcompesatory hemodynamic state in acute traumatic disease.

[Pathology of lungs by wounded in the armed conflicts in Northern Caucasus].

According to 7000 patient histories, wounded in armed conflicts in Northern Caucasus, for the last years, is marked a big part of wounds of mild (45.3%) and medium (31.5%) severity. Heavy and extremely heavy wounds marked conformably in 20.8 and 2.4 percents. An acute respiratory distress-syndrome is marked by 32 wounded with heavy and extremely heavy wounds, including 10--with penetrating wound of brainpan, 9--penetrating wound of bosom and tense hemopneumothorax, 11--penetrating wound of abdomen (with deflection of hollow and parenchymal organs), 2--penetrating wound of lower limbs (with firing breakup of long bones and deflections of great vessel), attended by blood loss and shock. Pneumonia was found during first 3 days after the wound by 47%, on 4-7 day--31%, during second week--13%, latter--9%. In 93% of cases pneumonia was marked in combination with traumatic shock. Radiological examining of radiological plays a conclusive account in diagnostics, and according to meanings--computerized tomography. Estimation of function of exterior breathing is also important.

[Respiratory support in elderly and senile victims with multiple traumas].

Studies of the specific features of acute posttraumatic respiratory failure in old age group victims with multiple traumas have provided an algorithm of mechanical ventilatory support. The advantage of early artificial ventilation with pressure monitoring is substantiated. There is evidence for the necessity of applying noninvasive ventilation in some cases. The proposed respiratory support tactics promoted a 12.1% reduction in mortality rates among elderly and senile victims in an intensive care unit.

[The fat embolism syndrome in severe combined traumas].

The authors discuss problems of prognosis, prophylactics, diagnosis and treatment of syndrome of fat embolism in severe combined traumas. On the basis of great statistical material a scale for prognosis of the risk of the development of the syndrome directly at the admission of the patient has been developed and a system of prophylactic measures is proposed started since the fist hours at the hospital. A scale for diagnosis has been proposed for diagnosis of the developed fat embolism syndrome. An original scheme of treatment is proposed. The schemes of prophylactics and treatment of the fat embolism syndrome as applied to a great number of patients allowed the frequency of occurrence of the syndrome to become three times less, and lethality of patients with the developed syndrome was more than two times less.

[An anesthesiologist-resuscitator's differential tactics in acute traumatic disease].

The detection of four forms of the course of acute traumatic disease (traumatic shock, acute respiratory failure, acute heart failure, and traumatic coma) leads to the conclusion that the multi pathogenic mechanism responsible for progression of the disease generates a need for differentiating the tactics of an anesthesiologist-resuscitator, beginning from the first hours after injury. Therapeutic tactics may be standardized within each specific form of an acute period of traumatic disease. Implementation of specific tactic programs for anesthesiological and resuscitative care in acute traumatic disease has promoted a reduction in mortality from 8.2 to 3.2% in this period.

[Some disputable issues of transfusion therapy in wounded patients].

On the basis of an analysis of the tactics of transfusion therapy in 272 wounded persons and victims with acute massive blood loss, the authors conclude that it is necessary to strictly follow the principle of individual directionality during blood transfusions. By taking into account the high risk of development of iatrogenic complications in the postshock periods of traumatic disease, it is expedient to do away with hemotransfusions in the advancing mode.

[Organization of anesthesiological and resuscitative care delivered to the wounded and patients in the large specialized hospital].

On the basis of an analysis of the specific features of organization of anesthesiological and resuscitative care, the authors formulate a number of points that are of great importance for the quality of work. They give the optimal recommendations for organizing the professional activities of physicians of intensive care units and consultants. The paper presents conceptual sketches of the training of anesthesiologists working in a specialized center are presented. The authors show it necessary to follow the principle in the gradation of anesthesiological and resuscitative care.

[Restrictions on use of prolonged and long-term artificial ventilation of the lungs in the wounded and casualties]. / Ogranichenie pokazanii k prodlennoi i dlitel'noi iskusstvennoi ventiliatsii legkikh u ranennykh i postradavshikh.

On the basis of an analysis of results of treatment of two groups of the wounded and casualties the authors render concrete indications and contraindications for prolonged and long-lasting artificial ventilation of the lungs.

[Specifics of intensive therapy in abdominal gunshot wounds]. / Osobennosti intensivnoi terapii pri ognestrel'nykh raneniiakh zhivota.

Among the wounded admitted to the departments of anesthesiology, resuscitation and intensive therapy there were from 57.8 to 77.6% of gunshot injuries of the abdomen. Successful treatment of such patients is dependent not only on the timeliness and quality of surgical interventions but also on the correct choice of intensive therapy before and during operation and in the postoperative period. The temporizing strategy providing for expanding the list of the methods used as late as the symptoms of the unfavorable course of the postoperative period can not be considered sufficiently effective. Complex intensive therapy with a forestalling action on different links of the wound disease pathogenesis in most cases allows not only the elimination of organic and systemic impairments resulting from the wound but also is more effective for defensive compensatory mechanisms. Differentiation of the programs of treatment depending not only on the severity of the patient's state but also on the character of injuries of organs of the abdominal and retroperitoneal areas is of the leading significance.

[The modern problems of intensive care in patients with wounds and traumas]. / Sovremennye problemy intensivnoi terapii u ranenykh i postradavshchikh.

The results of rendering the intensive care to 2244 patients with severe wounds and traumas were analyzed, which made it possible to define the most topical problems needed to be resolved, i.e. treatment schemes for patients with vegetative state (similar to coma) and with asthenic syndrome, perfection of intensive care for the elderly and absolutization of some intensive care techniques. Perspective solutions are suggested to cope with the above issues, which comprise a bigger quantity of rehabilitation centers, an elaboration of pathogenetic tactics of intensive care for the elderly patients and revising the feasibility of a long-term use of the intensive care methods with respect to the regulation and integration suppressed by such methods.

[Problems of prehospital care for a severe combined trauma]. / Problemy dogospital'noi pomoshchi pri tiazheloi sochetannoi travme.

The authors have analyzed the strategy and results of treatment of 455 casualties at the prehospital stage. Main defects of giving help at the prehospital stage and ways to improve it are described.

[Immunopathogenesis of severe wounds and traumas: possibilities of immune correction]. / Immunopatogenez tiazhelykh ranenii i travm: vozmozhnosti immunokorrektsii.

The authors describe the present-day views on the nature of immune dysfunctions in severe traumas. Based on personal clinical experiences and literature data the authors discuss the role of immune dysfunctions in pathogenesis of the traumatic disease. Special attention is given to the role of the immune system in the development of the life-threatening condition: polyorganic insufficiency whose formation mainly results from disorganization and functional failure of the system of immune reactivity. Clinical investigations have shown high effectiveness of early administration for severe wounds and traumas of a new means of immunocorrection--yeast recombinant interleukin-2 of man (preparation Roncoleukin). The administration of this immunocorrector in complex schemes of intensive therapy of the victims was shown to prevent the development of severe pyo-septic pathology and perfectly change the course of the traumatic disease.