(Greek trauma, trauma tos wound, damage; synonym: travmatora-
nevy exhaustion, a traumatic tuberculosis, wound exhaustion, dystrophy of wounded, an infectious nutritional dystrophy of seriously wounded, a cachectic form of sepsis, a gi-pergichesky or anergic phase of systemic infection) — the heavy dystrophic process developing in an organism of wounded and victims with the extensive injuries or burns complicated by suppuration. In relation to thermal burns speak about burn exhaustion or a toxic cachexia at burned.
Wedge, picture T. and. — a traumatic consumption as an effect of gunshot wounds, is more often than the extensive and followed by changes bones and suppuration, N. I. Pirogov in work of «The beginning of the general field surgery» (1865) for the first time described. In the subsequent only references of T occur in the domestic guides and works to field surgery. and. Problem T. and. underwent profound development in days of the Great Patriotic War when I. V. Davydovsky together with other researchers developed the doctrine about a bullet wound, a wound fever and T. and., original positions to-rogo kept the relevance and gained further development in a crust, time.
Danger of emergence and development of T. and. it is especially big at open difficult fractures of a femur and pelvic bones, wounds of a breast with heavy suppurative process in a pleural cavity, wounds and the closed injuries of a stomach with formation of intra belly abscesses and intestinal fistulas. Much more rare than T. and. it is observed at hron. the suppuration complicating open injuries of a skull; even more rare — at wounds of a brush and foot. On data. V. Davydovsky, based on experience of the Great Patriotic War, at 67,3% of the dead of T. and. there were wounds of a basin and a femur. At T. and. suppuration almost always has ichorous character, i.e. is followed by ichorization of fabrics what the «dirty» type of a wound and sharp off-flavor separated (testifies to see. Putrefactive infection). Exists close etiol. communication between extensiveness, depth, weight of damage of fabrics and development of T. and. However still N. I. Pirogov noted a possibility of development of T. and. at wounded with rather small damages of soft tissues, but with the deep and hidden purulent or putrefactive inflammation especially characteristic of zatek and intermuscular phlegmons.
TRAUMATIC EXHAUSTION 191
Krom of nature of wound, the important factor influencing emergence of T. and., is irrational to lay down. tactics. To the most frequent medical errors leading to emergence of T. and. at wounded and burned, belong: defective surgical treatment of a wound (insufficient section and incomplete removal of nekrotizirovan-ny fabrics), lack of drainage of a wound, untimely performing amputation, autoplastichesky closing of burn wounds.
In a pathogeny of T. and. three major factors are conventional: long suppuration of a wound, intoxication (see) and endocrine and metabolic frustration. However uniform assessment of value of each of the listed factors in literature is absent.
A. P. Avtsyn the main role in the mechanism of development of T. and. takes away hron. to disbolism of the infectious and toxic nature. In his opinion, long fever and the joining alimentary frustration lead to loss of appetite, disturbance of process of digestion and developing of diarrhea (see Ponosa). At the same time especially important role in a pathogeny belongs to loss of large amounts of protein and development of a hypoproteinemia. Similarity of a pathoanatomical picture of alimentary frustration at the dragged-out wound suppurative process and sepsis gave the grounds to pathologists and clinical physicians in due time to consider T. and. as special form of a course of a generalized purulent infection. With sovr. the positions considering reactivity of an organism, nek-ry researchers speak about T. and. as about a terminal phase of sepsis (see). This phase is characterized by sharp dysfunction of immunocytes (see. Immunocompetent cells) against the background of decrease in complementary activity of the blood serum leading to oppression of processes of activation of T - and V-lymphocytes, development of antibodies, and also excess products to them-mu nodep ress lymphocytes, iruyushchy from ubpopulyation. A. V. Rusakov, as well as most of the pathologists studying T. and. on materials of wartime, emphasized the leading role of long intoxication of an organism with the waste products of bacteria arriving from a wound (preferential from group of saprophytes). The last do not cause massive fusion of fabrics and the expressed inflammatory reaction, but lead to big loss of protein.
The pathogenetic scheme T is most recognized. and., proved by I. V. Davydovsky. According to it the leading role in development of T. and. plays hron. suppuration, long absorption of decomposition products of fabrics, occurring with active participation of microbes, and also massive loss of protein, enzymes and development of a vitamin deficiency (see). Long influence of toxic products causes heavy functional and morfol. changes in bodies and fabrics that predetermines transition is purulent - resorptive fever (see) in T. and. At a certain stage it is aggravated with endogenous frustration in went. - kish. path. The major functions, first of all a liver, including neutralizing, proteinaceous and educational, synthesis of enzymes, hormones, vitamins, antibodies, a glycogen are broken. There come deep digestive disturbances: in intestines inflammatory and atrophic processes develop that promotes increase of intoxication. Is later than T. and. gains irreversible character. I. V. Davydovsky fairly noted too general interpretation of the diagnosis «traumatic exhaustion» and allocated the dystrophic states developing at wounded with intestinal fistulas and also at long psychopathic
Pathoanatomical picture T. and. and various forms of a cachexia (see) it is almost identical. The widespread atrophy of fatty tissue, skeletal muscles, parenchymatous bodies is noted. Muscles lose up to 2/3 initial weights, gain gray-brown color, are easily stratified and torn; microscopically find a myolysis, thinning and splitting of muscle fibers (see the Atrophy muscular). Collagenic fibers bulk up and are exposed to glybchaty disintegration. The nervous device of muscles is involved in heavy dystrophic process that distinguishes T. and. from other types of exhaustion.
The expressed changes find in bodies of the alimentary system: cracks, atrophy of flavoring nipples and cover epithelium of language; mucosal atrophy of a stomach and small bowel; in a large intestine — a picture foul
kulyarno-ulcer colitis (see). In an origin of these changes along with intoxication dysbacteriosis (see), and also an intercurrent infection plays a role. The liver
is reduced in volume, dense, dark-brown color with uneven granularity (the phenomenon of cirrhosis). At the microscopic issl
a giving find an atrophy of hepatocytes, diffusion obesity, reorganization of hepatic beams,
growth of connecting fabric, limfoleykotsitarny infiltration of a stroma (intersticial hepatitis). The weight of heart owing to an atrophy sharply decreases (to 200 g), sharp
thinning and crimpiness of muscle fibers, adjournment of lipofuscin in cytoplasm of cardiomyocytes microscopically are found. The spleen is wrinkled, an atrofichna. Cases of its increase are connected with an exacerbation of local suppuration in a wound or with emergence of metastatic suppurative focuses. Heavy atrophic and dystrophic processes are observed in a hypophysis, thyroid and gonads. Morfol. changes in c. N of page designate as the dystrophic encephalopathy developing under the influence of intoxication and circulatory disturbances. Against the background of T. and. healing of wounds sharply slows down or completely stops. Granulations become sluggish, become covered by a scab, lose a granular look at the expense of a zapustevaniye of vessels. Again formed fabrics are exposed to a necrobiosis (see the Necrosis). In a wound there is a growth of various bacteria.
In general pathoanatomical picture T. and. it is characterized by the expressed atrophic and sclerous processes, against the background of to-rykh the inflammatory and dystrophic changes promoting deepening of an atrophy of bodies are shown (sometimes repeatedly). Formation of an irreversible stage morfol. reorganizations of bodies it is connected with development of fatty cirrhosis (see), a mucosal atrophy of a stomach and intestines.
A wedge, a picture of traumatic exhaustion, sepsis (see), a nutritional dystrophy (see) and nek-ry others patol. states it is quite similar. General condition of the patient always heavy. Bystry reduction of body weight is observed in the first i1! 2 months, further rate of a lose of weight decrease. The bone skeleton is boldly designated, extremities sharply become thinner. An animal force falls so that patients lose ability to stand, sit, and being in a bed, to raise the lower extremity. Hair thin; in occipital and parietotemporal areas the centers of baldness appear. Skin is pale, dry, with sharply reduced turgor. Patients are slowed down, lose interest in surrounding, become slovenly. In hard cases of burn exhaustion the general spasms, a myoclonia are observed (see). The progressing loss of appetite soon leads to anorexia (see). Taste is perverted, there are attacks of nausea and vomiting, is frequent out of communication with meal. Periodically there are abdominal pains. Wearisome ponosa in an end-stage of T. and. are replaced by involuntary defecation. Dystrophic hypostases (see Hypostasis), emergence, various on time (early, late, alternating) and a wedge, to manifestation — seen (hypostases of feet, shins, external genitals, an anasarca) and hidden develop (a hydrothorax, ascites, a hydrocardia). The person becomes bloated. Disturbance of a trophicity of fabrics and forced position of the patient in a bed leads to bystry emergence of decubituses (see). Temperature curve of the wrong type: strengthening of fever usually reflects emergence local (accumulation of pus in a wound) and the general is purulent - infectious complications. Indicators of vital capacity of lungs are sharply reduced (see). In lungs there are focal pneumonia (see Pneumonia), heart attacks, abscesses (see Lungs, diseases).
The most important sign of T. and. — increase of a hypoproteinemia due to preferential decrease in content of albumine (see). Parallel to it hypochromia anemia accrues (see), the neutrophylic leukocytosis and the accelerated ROE are noted. The general diuresis is reduced, however the iuriya more characteristic of a nutritional dystrophy is sometimes noted on l. In urine a small amount of protein is defined, leukocytes constantly meet, it is frequent — erythrocytes. The hemorrhagic syndrome is observed constantly with various a wedge, manifestations: the raised bleeding of granulations, went. - kish. bleedings, a hamaturia (see), a purpura (see) in a stomach and large joints, generalized capillary toxicosis.
In a wedge, it is difficult for practice to differentiate it is purulent - resorptive fever and T. and., and also to define transition of reversible intoxication from a suppurative focus in the progressing irreversible atrophy of internals. For the benefit of rescue of the patient it is more correct to consider all cases of the heavy purulent intoxication which is dragging on for 3 — 4 weeks, to already begun T. and., demanding intensive treatment. It is necessary to consider that at burns close dependence of frequency and weight of exhaustion on depth, the areas of defeat and terms of existence of a burn wound is also traced. The major pathogenetic factors of burn exhaustion are: an endotoxemia, plazmopoterya, bacteremia, the exhausting fever, emergence of pyoinflammatory processes in lungs, a liver and kidneys. In a burn wound the progressing delay of regeneration and rejection of a scab is observed. Granulations become thinner, turn pale, become sanguifluous and, at last, completely disappear, baring hypodermic cellulose, muscles, bones. On site wounds the crateriform ulcer forms. Between two types of exhaustion there are nek-ry distinctions caused by character of the damaging agents. For example, at T. and. ponosa are often observed, to-rye rather seldom meet at burns. The hemorrhagic syndrome, an ulceration of a mucous membrane of a stomach, a contracture of large joints are more characteristic of burn exhaustion. Among proximate causes of death at burn exhaustion pneumonia, a septicopyemia and gemorragichesk y a syndrome meet more often.
Active treatment of T. and. happens successful when fight against a putrefactive and purulent infection begins even before development of irreversible changes in an organism. At the same time the central place is taken by the active surgical methods directed to radical sanitation of a suppurative focus and the most bystry termination inf. process. In one cases it is necessary to make urgently repeated surgical treatment of a wound (see), to open purulent cavities, to adjust effective drainage (see), in others — amputation of an extremity or its segment according to vital indications (see Amputation). The dragged-out toxi-infectious process after a metalosteosynthesis at fractures of bones (see the Osteosynthesis) serves as the indication for removal of metal designs. If T. and. is result of long existence of outside intestinal fistulas, it is necessary to make operation on their closing timely. A timely autoplasty (see) burn wounds — the first condition of the prevention and removal of the patient from a condition of burn exhaustion. Before - and postoperative maintaining such patients demands active use of all arsenal sovr. methods of treatment it is purulent - a septic wound — enzymotherapy (see), biogenic stimulators (see), hyper baric oxygenation (see), hemosorptions (see t. 10, additional materials), ultrasonic therapy (see), diadynamic currents (see. Impulse currents), treatments in the abacterial environment (see. The managed abakteri-aljny environment), etc. Antibacterial therapy in the late period has limited value; it is shown at emergence of infectious and inflammatory complications (pneumonia) or at persistent bacteremia. Infusional therapy (see) it has to be carried out through the constant catheter entered into one of the central veins that allows to normalize quicker the volume of the circulating blood more effectively to struggle with anemia, a hypoproteinemia and disturbances of water and electrolytic balance. Svezhezagotovlen-ny donor blood, albumine, a protein, anti-staphylococcal plasma and immunoglobulin (gamma-globulin) are means of increase immunol. activities of an organism. Desintoxication of an organism is promoted by transfusions of Haemodesum, reo-Polyglucinum. Apply furosemide (lasixum), Novuritum, a dichlothiazide (hypothiazid) and other diuretics to fight against hypostases. For the purpose of bystry elimination of power deficit and recovery of intracellular protein use solutions of crystal amino acids, protein hydrolyzates, fatty emulsions, strong solutions of glucose. Caloric content of a daily diet shall make not less than 3000 kcal at protein content of 150 — 300 g. Before food it is useful to appoint divorced hydrochloric (salt) to - that with pepsin. When anorexia, nausea, vomiting interfere with natural meal, enter a stylet for a period of up to 30 days into a duodenum and more. Mixes for probe food select individually from the following products: beef-infusion broths, egg yolks, cream, vegetable and animal oils (in the kindled look), mineral salts, vitamins. These mixes enter kapelno in the warmed-up look.
The special attention is required by the general care of the seriously ill patient and prevention of decubituses (see). Each 1 — 11/2 hour of the patient shall change situation in a bed. Natural bone ledges protect rubber or wadded and gauze circles. The systematic occupations physiotherapy exercises (see) promoting the prevention of decubituses, pneumonia, a muscular atrophy are necessary. Patients are constantly induced to the maximum physical activity, observing at the same time the mode of the accruing loading. Lech. gymnastics it is reasonable to combine with warm a gigabyte. bathtubs.
The forecast at T. and. remains adverse, despite the increased possibilities of active fight
against an infection and disturbances of functions of the major bodies and systems.
Usually are a cause of death deep toakheksiya and atrophy of internals, metastatic suppurative focuses, apostematous nephrite (see), an amyloid nephrosis (see. And miloidoz), it is purulent - gangrenous ulcer colitis. Also insignificant bleeding as T can be a proximate cause of death. and. is followed by a decompensation of cardiovascular system.
See also Cachexia, Burns, Freezing injury, Wounds, wounds, Sepsis.
Bibliography: And in c y A. P N. Sketches
of military pathology, M., 1946; Guber g r and A. Ya c. Internal pathology of a fighting injury, M., 1946; Davydovsky I. V. Traumatic (gnoynoranevy) exhaustion, in book: Experience of owls. medical, in the Great Patriotic War of 1941 — 1945, t. 34, page 427, M., 1952; Pies N. I. The beginnings of the general field surgery, p.1, M. — JI., 1941; Wounds and a wound fever, under the editorship of M. I. Kuzin and B. M. Kostyuchenk, M., 1981; F and - V. I lats. Burn exhaustion, D.,
1968. V. A. Dolinin, G. N. Tsybulyak.