Gunshot injuries occur when a person is exposed to various types of firearms, injuring projectiles, small arms and explosive ammunition.

The latter include aerial bombs, artillery shells and mines, grenades and engineering mine ammunition, torpedoes, sea mines, rockets of all kinds, and volumetric explosion ammunition.

Gunshot injuries are divided into gunshot wounds (bullet and shrapnel), mine-explosive wounds and explosive injuries.

Combined injury is the result of simultaneous or sequential impact on the human body of a wounding projectile (gunshot or non-gunshot wound) and environmental objects (non-gunshot injury). For example, a combination of a gunshot wound to the chest and a closed craniocerebral injury as a result of a fall of the wounded.

Depending on the number and localization of injuries, gunshot and non-gunshot injuries are divided into isolated, multiple and combined.

Isolated injuries are injuries in which there is one damage to tissues, segments of the musculoskeletal system, or internal organs.

Multiple injuries are called injuries in which several injuries occurred (by one or more injuring projectiles, in relation to a gunshot injury) within the same anatomical region of the body.

Combined injuries are those in which several injuries occurred (by one or more wounding projectiles, in relation to a gunshot injury) in several anatomical regions of the body (head, neck, chest, abdomen, pelvis, spine, limbs).

According to the severity of gunshot and non-gunshot injuries are divided into four groups: light, moderate, severe and extremely severe.

Morphology and features of a gunshot wound.

As a result of the action of these factors, a gunshot wound is formed, which has an input, output (with a through nature of the wound) holes and a wound channel.

The wound channel of a gunshot wound often has a complex irregular shape and contours.

Within the wound channel, three zones of a gunshot wound are distinguished

The first - the zone of the wound defect - is formed as a result of the direct action of the injuring projectile. It is an irregularly shaped tortuous gap filled with wounded detritus, blood clots, foreign bodies, bone fragments when bones are damaged. This area is a guide in determining the direction of surgical treatment, and its contents must be carefully removed.

The second - the zone of primary necrosis - arises as a result of the action of all factors in the formation of a gunshot wound. These are tissues adjacent to the area of ​​the wound defect and have completely lost their vitality. Dead tissue must be completely excised and removed for the duration of surgical debridement.

The third - the zone of secondary necrosis ("molecular concussion" according to N. I. Pirogov) - is formed as a result of the action of the energy of a side impact and the formation of a runway. It has a mosaic character in terms of the severity of morphological manifestations, their size, extent and depth of location from the zone of the wound defect. Macroscopically, these changes are characterized by focal hemorrhages, reduced bleeding and tissue brightness, microscopically - microcirculation disorders in the form of spasm or paretic dilatation of well-marked vessels, stasis of uniform elements, destruction of cells and intracellular structures.
Secondary necrosis is a process that develops in dynamics (up to several days) and depends on the condition of tissue vital activity in the wound. Therefore, the main task of treatment in relation to this zone is to prevent the progression of secondary necrosis by creating favorable conditions for wound healing. The mechanisms of formation of secondary necrosis are complex and not fully understood. Ischemia is important due to severe microcirculation disorders, excessive proteolysis due to direct damage to cell structures and ischemic increase in the permeability of cell membranes, shock wave damage to subcellular structures.

A gunshot wound differs from wounds of other origin (stab, cut, chopped) in the following features:

1) the presence of a zone of necrotic tissue around the wound channel (primary necrosis),

2) the formation of new foci of necrosis in the coming hours and days after injury (secondary necrosis),

3) uneven length of damaged and dead tissues outside the wound channel due to the complexity of its architectonics (primary and secondary deviations),

4) often the presence in the tissues surrounding the wound channel of foreign bodies - deformed bullets, fragments, scraps of clothing fabrics, etc.

- this is tissue damage as a result of mechanical action. Accompanied by a violation of the integrity of the skin or mucous membrane. They differ in the mechanism of occurrence, method of application, depth, anatomical localization and other parameters. May or may not penetrate into natural closed body cavities (abdominal, thoracic, joint cavities). The main symptoms are gaping, pain and bleeding. The diagnosis is made on the basis of the clinical picture, in some cases additional studies are required: radiography, laparoscopy, etc. The treatment is surgical.

ICD-10

S41 S51 S71 S81

General information

A wound is an extremely common traumatic injury. It is one of the main reasons for contacting emergency rooms and issuing sick leave to outpatients. It occupies a significant share in the list of reasons for hospitalization in the trauma and neurosurgical departments, as well as in the departments of abdominal and thoracic surgery. Extensive injuries and injuries with violation of the integrity of the vessels often cause the development of shock and acute blood loss and, along with penetrating wounds, can be fatal. Possible combination with TBI, fractures of limb bones, chest injury, pelvic fracture, kidney injury and blunt abdominal trauma.

Causes of wounds

The cause of traumatic injury is most often a domestic injury, injuries resulting from accidents during sports, criminal incidents, road accidents, industrial injuries and falls from a height are somewhat less common.

Pathogenesis

There are four zones of the wound: the actual defect, the zone of injury (contusion), the zone of concussion (commotion) and the zone with a violation of physiological mechanisms. The defect may take the form of a surface (for example, with scalped or extensive superficial bruised injuries), a cavity (for example, with incised and deep bruised wounds) or a deep channel (with stab, through and some blind gunshot injuries). The walls of the defect are formed by necrotic tissues, between the walls there are blood clots, pieces of tissue, foreign bodies, and in the case of open fractures, there are also bone fragments.

Significant hemorrhages are formed in the contusion zone, bone fractures and ruptures of internal organs are possible. In the concussion zone, focal hemorrhages and circulatory disorders are observed - a spasm of small vessels, followed by their steady expansion. In the zone of disturbed physiological mechanisms, passing functional disorders, microscopic hemorrhages and foci of necrosis are revealed.

Healing occurs in stages, through the melting of damaged tissues, accompanied by local edema and fluid release, followed by inflammation, especially pronounced with suppuration. Then the wound is completely cleared of necrotic tissues, granulations are formed in the area of ​​the defect. Then the granulations are covered with a layer of fresh epithelium, and complete healing gradually occurs. Depending on the characteristics and size of the wound, the degree of its contamination and the general condition of the body, healing by primary intention, healing under the scab, or healing through suppuration (secondary intention) is possible.

Classification

Wounds are classified according to many different signs. According to the circumstances of application in traumatology and orthopedics, accidental, combat and operational wounds are distinguished, according to the characteristics of the injuring weapon and the mechanism of damage - cut, torn, chopped, stab, bruised, gunshot, bitten and crushed. There are also wounds that are of a mixed nature, for example, lacerations and stab wounds. Depending on the shape, linear, patchwork, star-shaped and perforated wounds, as well as damage with loss of substance, are distinguished. Wounds with detachment or loss of significant areas of skin are called scalped. In the case when, as a result of an injury, a part of a limb is lost (shin, foot, forearm, finger, etc.), the damage is called traumatic amputation.

Depending on the state of the tissues, wounds with a large and small area of ​​damage are distinguished. The tissues surrounding the wound with a small area of ​​damage, for the most part, remain viable, only the areas that were in direct contact with the traumatic instrument are destroyed. These injuries include stab and cut wounds. Incised wounds have parallel even edges and a relatively shallow depth with a relatively large length, and with timely adequate treatment, as a rule, they heal with a minimum amount of suppuration.

Blood can leak out (external bleeding) and into a natural body cavity (internal bleeding). In the latter case, an accumulation of blood is formed with compression of the corresponding organ and a violation of its function. With hemothorax, compression of the lung is observed, with hemopericardium - the heart, with hemarthrosis - all structures of the joint, etc. Minor superficial injuries, as a rule, are not accompanied by general symptoms. In severe injuries, there is a decrease in blood pressure, tachycardia, pallor of the skin and mucous membranes, nausea, dizziness, weakness and increased respiration.

Diagnostics

With small superficial wounds that are not accompanied by general symptoms, the diagnosis is made by a traumatologist based on the clinical picture. A detailed study is carried out in the process of PST. With extensive and deep wounds with a violation of the general condition, additional studies are needed, the list of which is determined taking into account the location of the damage. For injuries in the chest area,

PHO is performed under local anesthesia or anesthesia. The wound is washed, blood clots and foreign bodies are removed. The edges of the wound cavity are excised, the cavity is washed again and sutured in layers, leaving drainage in the form of a rubber outlet, tube or half-tube. If the area of ​​damage is normally supplied with blood, there are no foreign bodies left, the surrounding tissues are not crushed or crushed, and the edges are firmly in contact throughout (both on the surface and in depth), the wound heals by primary intention. After about a week, signs of inflammation disappear and a tender skin scar forms.

Injuries older than a day are considered as stale and are not subject to suturing. The wound heals either under the scab, which takes a little longer, or through suppuration. In the latter case, pus appears, a demarcation shaft forms around the damage zone. Suppuration is accompanied by a general reaction of the body - intoxication, fever, an increase in ESR and leukocytosis are observed. In this period, dressings and active drainage are carried out. If necessary, purulent streaks are opened.

With a favorable course, after about 2 weeks, the wound is cleared, the healing process begins. At this time, both local and general symptoms of inflammation decrease, the patient's condition returns to normal. The outcome is a rougher scar than with primary tension. With a significant tissue defect, self-healing may not occur. In such cases, plastic

Clinical signs of wounds. Violation of the integrity of the skin or mucous membranes, in some cases accompanied by damage to deeper tissues resulting from mechanical damage, is called an open injury, or wound.

The main clinical signs of a wound are pain, bleeding, gaping, dysfunction of the affected area of ​​the body.

Pain in case of injuries, it depends, first of all, on the number of damaged sensory receptors and nerve fibers. The nature and intensity of pain are determined by the localization of the wound, the nature of the injuring object, the speed of damage, as well as the individual peculiarity of pain perception and the reactivity of the body. The most painful wounds in the fingertips, mouth, perineum. The sharper the wounding object and the faster the damage is done, the less pain. The intensity of pain largely depends on the emotional state of the victim. With fear, a depressed mental state, a labile psyche, pain is perceived more acutely. Excitement, passion, neuropsychic recovery, on the contrary, reduce sensitivity to pain. The pain may increase with the development of an infection in the wound, tissue compression by edema, and the presence of foreign bodies in the wound.

Bleeding from the wound depends on the nature and number of damaged vessels (aorta, artery, veins, capillaries). Along with this, the nature of bleeding is due to the level of blood pressure in the body; the higher it is, the more bleeding. The initial state of the blood coagulation system is also important, such concomitant diseases as hemophilia and thrombocytopenia, in which even small wounds bleed profusely. In addition, bleeding largely depends on the type and nature of the wound: incised and chopped wounds bleed to a greater extent than lacerated and bruised ones, i.e. with frayed edges. In the crushed tissues, the vessels are crushed and thrombosed. The exception is the wounds of the face and head, where there is a pronounced vascular network that does not have the ability to subside when damaged. Another feature of head wounds is due to the significant displacement of the skin and underlying soft tissues, which often leads to scalping as a result of trauma.

The edges of the wound, depending on the elastic properties of the damaged tissues, their ability to contract, as a rule, gape. 3glow of the wound also depends on the type of traumatic object and the projection of the wound to the direction of the Langer skin lines. The greatest gaping of the wound was noted in the transverse dissection of the elastic fibers of the skin, with a large wound and sufficient elasticity of the tissues. The elasticity of tissues causes the displacement of the ends of damaged muscles, tendons, blood vessels and nerves to the depth of the wound edges. To a lesser extent, the wounds of internal (parenchymal) organs that do not have elastic structures gape.

The general reaction of the body to damage depends on the severity of the injury, which is determined by the size of the external wound, its depth, the nature of damage to internal organs and developing complications (bleeding, peritonitis, pneumothorax, etc.).

With any injury, a number of dangers pose a threat to the life of the victim. Injuries, like any injuries, can cause a general reaction of the body - fainting, shock, a terminal state. These phenomena develop not only as a result of pain irritation, but even more often due to bleeding from the wound and blood loss. Thus, the greatest danger in wounds is bleeding. No less dangerous in the later period is the infection, which, getting into the wound, can enter the body through it.

Classification of wounds. According to the causal factor, wounds are divided into deliberate (operating) and random .

Depending on the presence or absence of infection in the wound, it can be aseptic and infected. All wounds, except those caused by a sterile instrument during surgery, should be considered infected. If only the skin or mucous membranes are damaged, the wound is considered simple . In cases where such a wound is combined with damage to bone formations or internal organs, it refers to difficult .

Deep wounds in which the internal membranes of the cavities (abdominal, thoracic, skull, joint) are damaged are called penetrating . In such cases, the internal organs located in these cavities are often damaged. All other types of wounds, regardless of their depth, are non-penetrating .

Wounds caused only by mechanical damage are considered uncomplicated . Wounds exposed to any physical (radiation, burn, cold) or biochemical factors (poison, chemical and biological poisonous substances) are called complicated.

According to the nature of tissue damage, depending on the type of traumatic agent and the mechanism of injury, wounds are stab, cut, chopped, bruised, crushed, torn, bitten, poisoned, gunshot and mixed.

stab wounds applied with a sharp and long tool (knife, bayonet, nail, awl, etc.). A feature of these wounds is the large depth of the wound channel with a small diameter of the external damage. The wound channel is usually narrow; due to tissue displacement (muscle contraction, mobility of internal organs), it becomes intermittent and zigzag. With these wounds, internal organs, large vessels are often damaged with massive bleeding in the cavity or tissue, and the formation of aneurysms. Such injuries are most often complicated by the development of anaerobic infection.

cut wounds are applied with a sharp tool (knife, glass, razor, etc.) and are characterized by little damage to the edges, profuse bleeding and wide gaping of the edges. Such wounds usually heal by primary intention in the absence of infection.

Chopped wounds arise when damage is caused by a sharp heavy object (axe, saber, etc.). Such wounds are characterized by deep extensive damage to superficial and deeper tissues, combined with damage to the bones. In addition, chopped wounds are characterized by bruising, partial crushing of the edges, which leads to a longer duration of self-healing of wounds.

bruised And lacerations applied with a blunt object (hammer, stone, stick, etc.). Their edges are crushed with obvious signs of circulatory disorders as a result of damage to blood vessels and their thrombosis. Crushed tissues with multiple hemorrhages in them are a favorable environment for the reproduction of microbes.

Bite wounds occurs as a result of the bite of an animal or a person. Despite their limited size, such wounds are characterized by a significant depth of tissue damage and contamination by highly virulent oral flora. The course of such wounds is always complicated by a purulent or putrefactive infection. Rabies is a severe complication of animal bites.

gunshot wounds are very diverse and differ depending on the nature of the wounding weapon. There are bullet wounds, shot wounds and shrapnel wounds. The gunshot wound may be through when the wound has an inlet and outlet, blind when the traumatic agent gets stuck in the tissues, tangent when superficial damage to an organ or tissue is inflicted. The entry wound depends on the caliber of the firearm; it is always less than the day off. The higher the speed of the bullet, the more dangerous the damage in the depth of the tissues and the greater the damage in the zone of the exit wound. Gunshot wounds are characterized by a high degree of infection due to the ingress of scraps of clothing into the wound channel, as well as extensive tissue damage. They are characterized by the presence of a zone of destruction (wound channel) with crushing of tissues, a zone of bruising and tissue necrosis on the sides of the channel as a result of the impact of side impact energy, as well as a zone of molecular shock with structural changes in the nuclei and protoplasm of cells. Modern gunshot wounds are often multiple And combined . Combined wounds are those in which the projectile passes through a number of organs and cavities and simultaneously causes dysfunction of several organs.

poisoned wounds occur when bitten by snakes, scorpions, or when poisons or toxic substances enter the wound. These wounds, along with tissue damage, are characterized by damage to vital organs by toxic substances, which causes the death of the victims.

A special group consists of wounds inflicted by atomic or thermonuclear weapons. These wounds combine the action of mechanical (blast wave), thermal and radiation factors.

All body wounds, even clean operating rooms, can contain a certain amount of microorganisms. Accidental wounds are always infected, i.e. primarily contain microbes. Most often, staphylococci, as well as Escherichia and Pseudomonas aeruginosa, are determined in the wound. The entry of microorganisms into the wound at the time of injury is called primary infection , infection of the wound in the subsequent course is regarded as secondary infection .

In a primary infection, microorganisms, having entered the wound, adapt to new conditions within 6-12 hours without going beyond its edges. The development and reproduction of microorganisms is facilitated by blood clots, necrotic tissues, deterioration of blood circulation in damaged tissues, as well as a decrease in the protective immunobiological forces of the body as a result of shock, blood loss and other causes. After 12-24 hours, the infection goes beyond the wound, penetrating into the lymphatic and blood vessels, and is able to manifest its pathogenic properties. First of all, such activity is characteristic of anaerobes, then staphylococci and streptococci, and then saprophytes.

Secondary infection of wounds is a consequence of a violation of the rules of asepsis both in the provision of first aid and at various stages of wound treatment. Secondary infection causes activation of the inflammatory process due to increased pathogenicity of the existing microbial flora of wounds. The accession of infection significantly changes the course of the wound process, causing a prolongation of the healing time and the occurrence of various complications. All this determines the importance of the problem of preventing infection of wounds.

Prevention of primary infection consists in early active surgical treatment of wounds and the use of antibacterial drugs. Prevention of secondary infection is ensured by the strictest observance of asepsis at all stages of wound treatment.

The course of the wound process. With open injuries in the wound, cell death, lympho- and hemorrhage, thrombosis of small and large vessels with impaired blood supply to tissues occur. To eliminate the consequences of tissue damage (necrosis, hemorrhage, infection) and restore the integrity of tissues, the body mobilizes a number of protective mechanisms, which are divided into general and local reactions.

Considering the wound as a complex stimulus, the following main components are distinguished in it: pain, blood loss, plasma loss, poisoning by the decay products of tissues and vital activity of microorganisms, as well as metabolic disorders. Pain significantly alters the function of the cardiovascular, respiratory and excretory systems. This is expressed in increased heart rate, increased blood pressure, increased respiratory rate, decreased urination, etc. In cases of severe pain syndrome with injuries, shock may develop.

Bleeding and plasma loss always accompany an injury and, depending on its severity, can aggravate the physiological disorders caused by pain. In cases where blood loss is significant, it can independently cause the development of shock.

Intoxication associated with the absorption of the breakdown products of damaged tissue proteins and waste products of microorganisms always depends on the severity of the injury and the degree of infection of the wound. As a rule, in case of injuries, the protein and carbohydrate metabolism of the body first of all suffers, which is confirmed by the temperature reaction of the body. It is characteristic that during aseptic flow, wound process, the body temperature does not exceed 38 0 C and is not accompanied by chills and increased heart rate.

Local reactions to wounds imply a process aimed at wound healing, which depends on the following factors:

The general condition of the body, taking into account concomitant diseases and its general reactions to damage;

The state of metabolic processes in the body, due to the process of nutrition;

the age of the victim;

localization of the wound, taking into account the adequacy of the blood supply in this area and the necessary oxygen saturation of the tissues;

development of wound infection with subsequent complications.

Local reactions during injury, as well as the entire process of wound healing, consist of two successively developing phases.

hydration phase. As a result of disturbances in blood circulation and the development of oxygen starvation in damaged tissues, hydrogen ions and incompletely oxidized metabolic products accumulate: carbon dioxide, lactic, pyruvic and other acids. The more severe the injury, the more pronounced the developing disorders.

Clinical manifestations of the inflammatory reaction are explained by deep biochemical changes that occur in injured tissues, which ultimately lead to the expansion of the capillary network and blood stasis in them. The presence of these reactions explains the resulting hyperemia (redness).

Swelling is explained by tissue edema and stagnation in the capillary system due to osmotic hypertension that occurs in the wound area, as well as leukocyte infiltration.

Primary intention usually heals aseptic surgical wounds, as well as accidental wounds that have undergone early surgical treatment with suturing.

An increase in body temperature is associated with local activation of metabolic processes in the wound and increased blood flow in this area.

Pain is caused by damage to nerve receptors and conductors at the time of injury, as well as compression of their edematous fluid and irritation by an increased amount of acidic decay products. Pain syndrome limits the function of organs and systems.

The increase in edema, tissue infiltration, thrombosis of small vessels make normal tissue nutrition impossible. Progressive local tissue anemia leads to necrosis or significant degenerative changes in them.

In aseptic surgical wounds, the inflammatory reaction is much less pronounced than in infected wounds and practically does not require therapeutic measures. Along with the inflammatory reaction in the wound, there is a process of cleansing the focus of tissue damage from dead cells, toxins, and protein breakdown products. This process is provided by phagocytosis, enzymatic processes and removal of toxic products and microbes from the wound with inflammatory exudate.

Dehydration phase. The second phase of the wound process is characterized by the predominant development of restorative regenerative processes. In this phase, in connection with the development of a network of new capillaries and improved blood circulation, hypoxia and acidosis decrease in the wound, and as a result, the inflammatory reaction subsides in the wound. In the wound, vascular neoformation and the development of granulation tissue occur, followed by the formation of a scar.

Types of wound healing. It is customary to distinguish between two types of wound healing: primary and secondary intention. In addition, there is still healing under the scab.

Wounds heal by primary intention, provided that their edges are in close contact. Such healing is characterized by fusion of the wound edges without macroscopically visible intermediate tissue.

The conditions necessary for wound healing by primary intention are:

tissue viability;

tight contact of the edges of the wound;

absence of infection

absence of hematomas, foreign bodies and necrosis in the wound area.

Healing by primary tension begins with the primary gluing of the edges of the wound adjacent to each other due to fibrin, which is formed from the exudate that poured out into a narrow gap between them. During the first 3-5 hours after the injury, polymorphonuclear leukocytes enter the wound zone, which phagocytize microorganisms, their decay products, the remains of damaged tissue and blood cells. The fibrin formed in the wound undergoes local fibrinolysis, and the tissues of the wound edges grow together. Healing by primary intention is the most perfect type of regeneration, as it does not leave rough scars and is completed in 7-8 days.

Healing secondary tension observed with a large gaping of the edges of the wound with the formation of a cavity, in the presence of a purulent infection in it, tissue necrosis and foreign bodies .

In these cases, at the first stage, the wound is cleansed of necrotic tissues, infections and foreign bodies. . Then, on the 3rd day from the moment of injury, areas of granulation tissue appear at the edges of the wound. It is presented in the form of a framework of newly formed capillary loops surrounded by young connective tissue cells, fibroblasts, macrocytes, and leukocytes. Gradually granulation tissue fills the wound cavity. It performs a barrier function, protecting the body from the penetration of microorganisms and their toxins. The main function of granulation tissue is to protect the body from external influences.

As the wound fills with granulations, fibroblasts turn into fibrous connective tissue, from which a scar is subsequently formed. Cicatricial transformation of granulations leads to a decrease in the size of the wound. So, at a normal rate of healing, the area of ​​the wound defect per day can be reduced by 10-15%. After filling the wound with granulations, the epithelium begins to creep due to cell migration to the newly formed granulations. As a rule, epithelialization begins from the edges of the wound, towards its center. With large tissue defects, sometimes there are areas of granulations that are not covered by the epidermis. In secondary healing, epithelialization is absent until the replacement of the defect with granulations to the level of the skin is completed.

Thus, wounds that heal by secondary intention are characterized by:

rapid disintegration of damaged tissues;

their rejection by sequestration into the wound channel;

Active participation of microflora in tissue breakdown;

development of granulations.

Healing with superficial wounds (abrasions) and shallow burns in some cases occurs under the scab . A dense crust (scab) is formed on the surface of wounds from erythrocytes, leukocytes and fibrin, which plays the role of a protective bandage. In the absence of infection, small wounds under the scab heal in a few days, while a delicate scar gradually forms. After epithelialization of the wound surface, the scab departs on its own.

Complications of wounds. The nature of the complications resulting from injuries largely depends on the phase of the wound process.

In the first hours after the injury, the most dangerous are: bleeding, acute anemia, shock, dysfunction of vital organs damaged by injury, infection of the wound with the subsequent development of local or general (purulent, putrefactive or anaerobic) infection, damage to the nerve trunks with the occurrence of paresis and paralysis . In the hydration phase with extensive wounds, severe phenomena of lymphangitis, lymphadenitis, erysipelas, secondary bleeding due to erosion of the vessel by a purulent process can develop.

With extensive and deep wounds, the purulent-inflammatory process can proceed so rapidly and quickly that the body does not have time to create a protective shaft around the abscess. In such cases, a breakthrough of the infection into the bloodstream and its spread to all organs and tissues is possible - the development of a general infection (sepsis).

In the phase of dehydration from the side of the wound, both general and local complications can be observed. Common causes of poor wound healing include hypoproteinemia, metabolic disorders, and severe comorbidities. Local causes of poor granulation formation include infection, areas of necrosis, and foreign bodies. In some cases, there is an excessive growth of granulations (granula - grain), which indicates the presence of a foreign body (ligatures, metal fragments) or an infected sequester in the depth of the wound.

During the scarring period, processes of wrinkling of the scar can be observed, which is fraught with the formation of disfiguring deformities and contractures if the process is located near the joints. Excessive scarring is called a keloid, the latter can also lead to deformities and contractures. Circulatory disorders and Innervation of the wound area can lead to the development of long-term non-healing trophic wounds.

Wound treatment. The goal of wound treatment is to restore the integrity of damaged tissues and organs with full preservation of their functional features. To achieve this goal it is necessary:

Timely and correct provision of first aid;

Qualified performance of primary surgical treatment of the wound;

Careful care of the wounded and pathogenetically substantiated treatment.

basis first aid for wounds is the initial treatment of the wound. At the first moment after the injury, the most formidable danger is bleeding, so the first measures should be aimed at stopping. Bleeding in any possible way (pressing the vessel, applying a tourniquet, pressure bandage). An equally important task of first aid is to protect the wound from contamination and infection. Wound treatment should be carried out with clean, preferably disinfected hands. Before starting to apply a bandage, it is necessary to remove dirt, earth, scraps of clothing from the surface of the wound and adjacent skin areas with tweezers, a piece of gauze or cotton wool. After that, in the presence of disinfectants (hydrogen peroxide, furacilin solution, alcohol solution of iodine), it is necessary to widely treat the skin around the wound 2-3 times. This prevents infection of the wound from the surrounding skin after the dressing is applied. Cauterizing antiseptic substances should not be allowed to enter the wound, as they can cause cell death, and this contributes to a sharp increase in pain. When applying an aseptic dressing, you should not touch those layers of gauze with your hands that will be in direct contact with the wound. In case of shallow, superficial wounds, traumatic small foreign bodies that have penetrated the skin (fragments of glass, metal) cause pain and infection of tissues, and therefore, when providing first aid, it is advisable to remove them with tweezers or a clamp. Foreign bodies from large and deep wounds can only be removed by a doctor when performing primary surgical treatment. Do not rinse or dry the wound before applying a dressing. To fix the bandage, you can use adhesive plaster, cleol, as well as mesh-tubular bandages.

The wound should not be covered with powders, ointment should not be applied to it, cotton wool should not be applied directly to the wound surface - all this contributes to the development of infection in the wound.

Sometimes internal organs (brain, intestine, lung) can be presented to the wound. When treating such a wound, it is impossible to immerse the fallen organs into the depth of the wound, the bandage must be applied over the fallen organs.

In the future, the task of first aid is reduced to maintaining the regenerative forces of the body, which is achieved by ensuring complete rest of the damaged area due to proper immobilization and transportation. With extensive wounds of the limbs, they should be immobilized, capturing both adjacent joints.

The most important task of first aid to the wounded is their speedy delivery to a medical institution. The sooner the victim receives medical attention, the more effective the treatment. It must be remembered that prompt delivery should not come at the expense of proper transportation. The tasks of first aid for the wounded include the prevention of tetanus, especially if they are to be transported over long distances. In this situation, the introduction of painkillers is indicated. The wounded should be transported in a position that minimizes harmful effects, concussions and takes into account the nature of the injury, its location and the degree of blood loss.

All the wounded at which damage was accompanied by the occurrence of shock, as well as significant blood loss, must be transported only in the supine position, accompanied by medical personnel.

Treatment of fresh wounds varies depending on the degree of infection.

Random wounds in each case should be considered infected. The infection is introduced into the wound, both at the time of injury, and in the following hours during dressing, transportation, etc. At the prehospital stage, in order to prevent secondary infection, the skin around the wound is widely treated with 5% iodine tincture, and the wound is closed with an aseptic dressing. After performing these manipulations, the patient is urgently taken to a medical institution.

In a hospital, depending on the condition of the patient, the nursing staff should provide him with first aid, which consists in giving the patient a position that improves blood circulation to the brain and reduces pain. In addition, the patient should be injected with tetanus toxoid, and if necessary, give him heart medication, provide oxygen inhalation, give him a sniff of ammonia.

Bleeding.

Bleeding is the most dangerous complication of wounds, directly threatening life.

* Bleeding - is the release of blood from damaged blood vessels. This bleeding is called traumatic. Bleeding may be non-traumatic. It occurs when a vessel is corroded by a painful focus (tuberculous, cancerous, ulcerative).

Bleeding from capillaries and small vessels most often spontaneously stops in the next few minutes, since blood clots (thrombi) form in the lumen of damaged vessels due to blood coagulation, which clog the bleeding vessel. However, with reduced blood clotting (with radiation sickness, hemophilia), damage to even small vessels can cause prolonged, and sometimes life-threatening bleeding and blood loss. Bleeding always leads to loss of blood from the body.

Slight bleeding, and, consequently, a small blood loss does not entail any harmful consequences for the body. Severe bleeding and large blood loss pose a significant danger to the human body and can be fatal.

Given the serious consequences and the risk of severe bleeding and profuse blood loss, it should be considered one from main tasks first aid with injuries stop bleeding and eliminate its consequences(acute blood loss).

Blood loss and criteria for its assessment. The human body contains 70 ml of blood per kg of body weight. Loss of 1/4 of the blood life threatening , a 1/2 - dose deadly. In children, less blood loss is also dangerous.

The greatest danger is the simultaneous acute massive blood loss; if it reaches 2 - 2.5 liters, then death usually occurs. The loss of 1 - 1.5 liters of blood is manifested by the development of a severe clinical picture of acute anemia, which requires emergency resuscitation and intensive care. The amount of blood loss can be judged by the amount of blood shed, by clinical data (consciousness, skin color, blood pressure and heart rate, pulse change), as well as on the basis of laboratory data (hemoglobin level, hematocrit and bcc).

According to these signs, there are three degrees of blood loss: mild, moderate and severe.

At mild degree blood loss, heart rate ranges from 90-100 per 1 min, systolic blood pressure is not lower than 100 mm Hg. Art., hemoglobin and hematocrit remain unchanged, BCC decreases by 20% or less.

Average degree characterized by increased heart rate up to 120 - 140 in 1 min, systolic blood pressure decreases to 80-70 mm Hg. Art.

At severe blood loss, there is a sharp pallor of the mucous membranes and skin, cyanosis of the lips, severe shortness of breath, a very weak pulse, a heart rate of 140-160 per 1 min. The hemoglobin level decreases to 60 g/l and below, the hematocrit index - up to 20%, BCC - by 30-40%.

With moderate and weak bleeding, hemodynamic disturbance is maintained at a satisfactory level for a long time due to compensatory reactions of the body.

With large blood loss in first In turn, the function of the brain is disrupted, and then the functions of other vital organs (heart, lungs, kidneys) are disrupted, as there is insufficient blood supply to the organs with oxygen

Complications of bleeding. The most common complication is acute anemia, which develops with the loss of 1-1.5 liters of blood. The clinical picture in this case is manifested by a sharp violation of blood circulation. A sudden decrease in BCC causes a sharp deterioration in heart function, a progressive drop in blood pressure, which, in the absence of medical care, leads to the development hemorrhagic shock. Severe microcirculation disorders occur in various organs: impaired blood flow in capillaries, aggregation of erythrocytes (gluing of erythrocytes into coins), the appearance of microclots, etc. In the lungs, this leads to impaired gas exchange, the blood is poorly saturated with oxygen, which, in combination with a sharply reduced BCC, oxygen starvation of all organs and tissues. Hemorrhagic shock requires emergency resuscitation and intensive care. The later the treatment of acute anemia is started, the more irreversible are microcirculation and metabolic disorders in the body of the victim.

A less formidable complication is compression of organs and tissues outflow of blood - cardiac tamponade, compression and destruction of the brain. These complications are so dangerous that they require emergency surgery.

When large arteries located in large muscle masses are injured, large hematomas can form that can compress the main arteries and veins and cause gangrene of the extremities. Hematomas can cause the development of the so-called false arterial, or arteriovenous, aneurysm - a sac-like formation in which blood circulates.

When large main veins are injured, at the moment of deep inspiration, negative pressure arises in the vein and air through the gaping vein can enter the heart cavity - there is air embolism endangering the patient's life.

After acute blood loss, the development of coagulopathic complications due to disorders in the blood coagulation system is possible. As is known, there are a number of factors in the blood (proteins, enzymes, etc.) that prevent blood coagulation in the bloodstream or its release into the surrounding tissues through the walls of blood vessels. These substances are combined into the concepts of coagulation and anticoagulation systems, which are normally in dynamic equilibrium. The coagulation system includes prothrombin, fibrinogen, calcium ions, etc., and the anticoagulant system includes heparin, fibrinolysin, etc.

In the first minutes and hours after blood loss, the coagulation system is activated in the body - the amount of fibrinogen and prothrombin increases, a hypercoagulable state of blood develops, due to which the outflowing blood quickly coagulates and the resulting clot can close the defect in the vessel and cause spontaneous stop bleeding.

This activation of the blood coagulation system also contributes to the formation of blood clots in the capillaries, which consumes fibrinogen; at the same time, a large number of thrombogenic substances are lost with the outflow of blood. In addition, the concentration of clotting substances in the blood decreases due to the dilution of blood (hemodilution) by the fluid coming from the interstitial spaces. All these factors lead to the development of a hypocoagulable state of the blood, which can cause secondary and very severe diapedetic bleeding, i.e. bleeding through an intact vessel wall. Most often, such bleeding occurs in the lumen of the gastrointestinal tract, trachea and bronchi, kidneys and bladder.

From all that has been said, it is clear that the sooner the bleeding is stopped, the more favorable its outcome.

Symptoms of acute blood loss and acute anemia:

complaints of weakness, fatigue;

· noise in ears;

sharp, progressive pallor of the skin and visible mucous membranes (lips, auricles, nail beds);

cold clammy sweat

Weakening or blurred vision

quickening of breathing;

frequent and small pulse (its weakening up to complete disappearance);

a sharp decrease in blood pressure;

Decreased hemoglobin content in the blood; at absence aid appears signs of a terminal state.

Types of bleeding.

I. Depending on the nature of the damaged vessels distinguish:

arterial,

venous,

parenchymal,

capillary bleeding.

II. depending from places of bleeding distinguish:

· external bleeding- when blood is released through a wound of the skin or mucous membrane;

· internal bleeding- when blood is poured into tissues, organs and cavities.

When tissue bleeds, blood soaks it, forming a swelling called infiltrate or bruising . If the blood impregnates the tissues unevenly and, as a result of their expansion, a limited cavity filled with blood is formed, it is called hematoma .

III.Depending on time of bleeding after damage is classified as:

· primary bleeding- occurs immediately after injury;

· secondary bleeding- occurs some time after injury or injury (after a few days or weeks, i.e. when the wound should already be healing - this indicates infection of the wound).

Signs of bleeding.

· arterial bleeding- the most dangerous bleeding. It occurs when more or less large arteries are damaged. In a short period of time, a large amount of blood is poured out of the body.

Bleeding characteristics: scarlet blood flows out of the wound in a strong jerky, pulsating stream, since the blood in the arteries is under pressure and enriched with oxygen.

Damage to large arteries (femoral, brachial, carotid) poses a threat for the life of the victim.

· Venous bleeding- occurs when more or less large veins are damaged.

Bleeding characteristic

Traumatology and Orthopedics Olga Ivanovna Zhidkova

11. Soft tissue injuries

11. Soft tissue injuries

Soft tissue injuries include injuries to the skin, mucous membrane, deep-lying tissues (subcutaneous tissue, muscles, etc.), as well as tendons, blood vessels and nerves. As a result of violation of the integrity of the skin, microbial contamination of the wound surface occurs, which can lead to the development of a banal or anaerobic infection.

Classification of soft tissue injuries

Cut wounds result from the direct impact of a sharp weapon on the surface of the skin.

Chopped wounds are formed when a sharp weapon is lowered onto the skin at an angle.

Stab wounds are the result of deep penetration of a sharp thin instrument. Possible injury to the cavities or joints.

Contusion wounds occur when some part of the body comes into contact with a hard obstacle and there is a solid support in the form of the bones of the skull or other bone.

Crushed, crushed wounds are formed due to the impact of a blunt instrument with a wide surface when opposed to a solid support.

Bite wounds. As a result of a bite by an animal or a person, highly virulent causative agents of wound infection can enter the wound.

Rats, mice, cats, dogs and foxes are carriers of a serious infectious disease - rabies. Snake bites are especially dangerous due to the possible development of paralysis (as a result of the action of a neurotoxin) and hemolytic complications.

Insect bites cause local swelling, redness, and central necrosis at the site of the bite. Sometimes there is inflammation with abscess formation.

Gunshot wounds can be penetrating or blind. Bullet wounds are more severe and more often fatal than shrapnel wounds. Mine-explosive wounds are accompanied by multiple crushed fractures, primarily of the bones of the foot and the lower third of the lower leg, massive detachments of muscle groups and exposure of the bone over a large extent.

Wounds can be single and multiple. Combined wounds should also be distinguished, when one injuring agent damages several organs. When damaged by chemical or radioactive agents, one should speak of a combined lesion.

In relation to the cavities, wounds are divided into penetrating and non-penetrating.

First aid when injured, it is aimed at stopping and preventing microbial contamination and the development of infection.

For any wounds, tetanus toxoid is administered in the amount of 3000 AU according to Bezredko.

Superficial small wounds that do not penetrate into the body cavities and are not accompanied by damage to large vessels and nerves, tendons and bones are subject to outpatient treatment.

Cut and chopped wounds with smooth edges are not subject to surgical treatment.