Diagnosis injured no doubt in the presence of wound yarn wall Vaught. It is more difficult to solve the question – is the wound non-penetrating or does it penetrate into the abdominal cavity. Absolute and direct indication of Prony Penitent injury is loss from the wound of the internal organs and TKA it (most of all – the strands of the greater omentum, rarely – small bowel loops), discharge from the wounds of the intestinal contents, bile, urine, with the corresponding conductive bandages staining (linen) and smell .
In the absence of the above symptoms the diagnosis penetrating injuries pose based on indirect symptoms indicating Nali Chie abdominal abnormal contents (blood, intestinal with the contents of the, urine). The presence of large amounts of blood in the peritoneal cavity is combined with signs of general hemorrhage, and ventricular contents but tract and incontinence – with signs of intoxication and peritonitis.
Since signs of damage to the abdominal organs have much in common, both with wounds and with a closed injury, they will be described below. Here it should be emphasized that in cases of doubt, when symptoms from unclear abdominal or absent, windows final conclusion about the nature of wounds after only tolerate your primary hydrochloric surgical treatment of abdominal wounds. In some cases, s, with stab wounds of the large muscle arrays border with Ms. votom areas (lumbar, inguinal region, the buttock region) diagnosis about permeating injury can be established as a result of vulnerografii.
Method vulnerografii consists in that under local anesthesia wound around the cleft opening applied purse string suture strong thread (silk, lava san). A sterile pediatric urinary catheter is carefully inserted into the wound channel to the possible depth, around which the purse string suture is tightened tightly. Syringe under pressure Niemi injected through the catheter 20 ml of 20% water-soluble X-ray contrast and make vsky shot in two projections. When penetrating wounds contrast agent enters the peritoneal cavity, intestinal loops between spreading and causing bole stems sensations. In non-penetrating wounds, contrast in the form of a lake accumulates in soft tissues. However, it should be recognized that the negative data vulnerografii do not allow absolutely, completely eliminate the pervasive nature of the wound Niya. Undoubtedly, the advantage of the method is that the surgeon becomes izve stnym general direction of the long wound channel that facilitates lane between primary surgical treatment (when there are indications).
Closed damage health of the victim is not always with sponds to the actual severity of the damage. Thus, at break age himatoznyh organs or small intestine being in the first hours after the trauma may be satisfactory, while the abdominal wall injury without damaging internal organs immediately after injury can give the impression of heavy damage. The main complaint we had suffered Shih are abdominal pain of various localization, intensity and IR radiation. If the liver is damaged, pain is given in the shoulder girdle on the right, with a spleen injury – on the left. There may be complaints of dry tongue, nausea, vomiting, gas retention, lack of stool, difficulty urinating.
On examination, above all, should pay attention to the general when signs of acute anemia due to internal bleeding – pale skin and visible mucous membranes, cold sweats, rapid shallow breathing, frequent (more than 100 beats per minute.) Pulse weak on complements, low ( less than 100 mm Hg) blood pressure, dry tongue is often observed with trauma to the hollow organs. Bleeding caused Noah rupture of the kidney, can manifest massive hematuria.
On examination, the abdomen can detect abrasions, bruises and a CRO voizliyaniya. However, the lack of them on the abdominal wall does not exclude the Nali -being severe internal injuries. You should pay attention to the presence of bloating, its asymmetry as a result of various “swelling”. An important sign of damage to internal organs is the disappearance of respiratory excursions of the anterior abdominal wall.
Diffuse voltage muscles of the anterior abdominal wall and painful NOSTA its palpation, especially in the umbilical ring are signs indicating the damage to internal organs.
Bloating (without muscle tension) is not a reliable sign of damage to internal organs; abrupt bulge arises present in the first 2 hours after injury, characteristic retroperitoneal hematoma. Expressed bloating and muscle tension observed in Build gave a general purulent peritonitis, brought in more than 12 hours after the trauma of hollow organs. In such cases pathognomonic symptoms suggestive of peritonitis due to deterioration vnut nal bodies is symptom-Shchetkina Blumberg, which may be absent during the first hours after the trauma. In cases of abdominal pain and bleeding observed positive symptoms times Drazhenom peritoneum is voltage anterior abdominal wall ki (Kulenkampfa symptom). Shortening of percussion sound in the side of affairs stomach indicates congestion in abdominal free Yid bone (blood, exudate, transudate, intestinal contents, pus, urine, etc.). In contrast, retroperitoneal hematoma, in which also determines the camping shortening of percussion sounds, but the limits of this shortening is not me are (a symptom of Joyce), the boundary of shortening that occurs in the presence of free fluid is moved by turning the victim on his side.
When a hollow organ ruptures in the abdominal cavity, free gas can be determined, which, accumulating under the right dome of the diaphragm, gives a decrease or disappearance of the zone of shortening of percussion sound over the liver area. This attribute indicates the hollow organ gap od Nako absence of this feature does not exclude such a gap.
Absence of bowel sounds at the victim concurrently with mennom no abrupt swelling indicates injured internal organ new. Bloating and the absence of peristaltic murmurs can occur with retroperitoneal hematoma and in the late stages of peritonitis.
Diagnosis of retroperitoneal hematoma is difficult and responsible nym case. Usually, the victims are in serious condition, they Naru Chenault consciousness due to traumatic brain injury, there are signs of acute blood loss that the presence of rib fractures fire limb fractures with hemo thorax is understandable. The diagnosis is usually made during a dynamic clinical and instrumental examination (radiography, ultrasound, CT).
From clinical signs indicative of the retroperitoneal hematoma most Symp that Joyce: shortening percussion sound zone over hematoma does not vary with the affected body position, unlike in a free liquid bryush hydrochloric cavity, which is moved by change of body position.
Noteworthy is the development in the first hour after injury express pas bowel cutting, unlike paresis like symptoms of peritonitis, which occurs later, after 8-12 hours after injury.
In the presence of associated injuries value of clinical symptoms in indoor and closed injuries of the abdomen falls sharply: muscle tension anterior abdominal wall is observed in patients with traumatic brain injury or a re fractures at edges; in victims who are unconscious, impossible can reveal abdominal pain, symptom Shchetkina-Blumberg, etc. Often, when we pass the spine lomah, lower ribs, pelvic bones, with retroperitoneal hematomas fuss cabins pseudoperitonitis symptoms (bloating, depression peristalsis, weakly zhitelnye symptoms of peritoneal irritation). Therefore, with a closed abdominal injury, a number of objective research methods, both non-invasive and invasive, are currently used.
The oldest and most common is the method of ra- phy. If you allow the condition of the victim, it examined in putting SRI standing and then – lying on his back, lying on its side.
In the study of standing pay attention to the presence of free gas at Kupo Lamy diaphragm. It is believed that the free gas is best detected when the position of the victim on the left side and the horizontal direction X-lu whose (laterografii).
Free fluid in the abdominal cavity is detected as a parietal platen prominent shadows in the lateral channels and increase mezhpetlevyh intervals CCA cially well visible on the background of pneumatosis intestine. On a panoramic radiograph, the retroperitoneal hematoma looks like a diffuse shadow, against which the shadow of the iliopsoas muscle disappears (i.e. Ileopsoas ). In case of fractures of the pelvic brushes, it is necessary to exclude damage to the bladder, which is achieved by contrast cystography. In this case, retroperitoneal hematoma causes deformation and displacement of the urine Vågå bubble, which is clearly seen on cystogram. More topical diagnos tic with abdominal trauma does not make much sense, because presence of pathological with contents of the abdominal cavity is the absolute indication for surgery. However, the X-ray method is time consuming and diagnostic dos tovernost does not exceed 70 %.
If you suspect a bladder rupture shall assess the results of kata terizatsii bladder and, if indicated, a contrast cystography.
As mentioned above, the impossibility or difficulty self parking Tel’nykh urination causes injured organs suspected urine excretion. If the catheter is received over 1 l of bloody urine should be suspected intra-bladder rupture (will do of fluid from the abdominal cavity). However, the absence of this feature does not allow to exclude such a gap.
In an unsuccessful attempt of the catheter into the bladder catheters polarization should be discontinued. The appearance of a small amount of fresh blood in this case indicates an injury to the urethra. In such cases, instead of cystography, urethrography is performed .
If necessary, the surgeon should independently perform these studies. Cystography is performed as follows. Under the conditions of asepsis in the previously emptied bladder Janet syringe through a catheter introduced into 250-300 ml of 20% water soluble contrast agent. After contrast injection into the bladder kata ter occluded hemostat and makes ray three shots: shot straight pelvis, bladder picture in oblique projection and direct pelvis picture after emptying the bladder of the contrast solution.
In analyzing the results pay attention to the position of the bladder, its shape, size, outline, presence of contrast solution flowing in the eye lopuzyrnuyu fiber (at extraperitoneal discontinuities, and / or into the free peritoneal cavity (for intra discontinuities).
When urethrogram urinary catheter is performed only to the obstacle location and after administration of 20 ml of 20% contrast solution make two pictures in the forward and oblique projection tion. Leaking contrast agent for the contours of the urethra Svyda ments about the injury.
Ultrasonic diagnostic method does not require special equip vannogo space and can be carried anywhere – on the couch front desk, on a gurney, on the operating table. The doctor has the possibility of observed for the ultrasound picture on the screen of the device in real time, while on the study takes a few minutes.
Signs of the presence of free fluid in the abdominal cavity are the disconnection of the parietal and visceral sheets of the peritoneum in the flat areas of the abdomen and in the pelvic area. The more fluid (blood) in the abdominal cavity, the further the peritoneum leaves are separated from each other. The value of the ultrasonic method of the study is, in addition, that with it easily possible to visualize those damaged organs is new, which did not lead to the emergence of intra-abdominal bleeding.
In particular, it is a diagnostic and central subcapsular hematomas Pec audio, different lesions of the kidneys and pancreas. Application of Ultrasound kovogo method enables dynamic monitoring of the state of the parenchymal organs and in time to put the indications for surgical treatment (in the example, by increasing the size of the hematoma intraorganic with a tendency to break into the abdominal cavity).
At the same time, this method is not without drawbacks. He contributes little to the diagnostic ki damages of hollow organs. Expressed flatulence or presence emfi soft tissue zemy shield almost the entire picture with a belly polo side STI and makes ultrasound ineffective.
Method X-ray computed tomography is used in cases when it is necessary to specify the state of parenchymatous organs, aorta, hemorrhage foci in the abdominal cavity and retroperitoneal about space.
Since this study has been performed in a special room for a rather long time, it is possible only with stable hemodynamics of the patient. Nali Chiyo ventilator is not a contraindication to CT. Before examining usually produ DYT contrast enhancement parenchymatous organs, to which 50 ml of intravenously administered officinal omnipaka solution. The density of organs and tissues is determined by the Hounsfield scale in units of H, according to which the value [-1000] corresponds to the density of air, the value  – to the density of water and the value [+1000] to the density of flat bones.
After performing the axial slices all abdominal evaluated greatness well organs, their structure, and the volume of hematoma structure, the presence of discontinuities parenchyma pathological content volume in the peritoneal cavity and retroperitoneal space stve.
At the same time it should be emphasized that the presence of large amounts of gas in about the light of the gastrointestinal tract (paresis, after endoscopic studies Nia), emphysema, soft tissue, foreign metal bodies in tissues and metalliches FIR designs on the victim’s body (for example, the imposition of vehicles external fixation for pelvic fractures) – reduce the diagnostic capabilities of the RCT. A large radiation load on the patient forces a strict approach to the testimony of the study in dynamics.
Paracentesis of its simplicity, rapidity and effektivnos Tew. However, for its safe execution some experience is necessary, because in inept hands, he himself can lead to trauma to the underlying intestine, or (with the wrong technique) to a false conclusion.
Contraindications and its application is the sharp bloating and presence of multiple postoperative scarring of the anterior abdominal wall, indicating a high probability of adhesions with fic * FIG intestinal loops to the anterior abdominal wall.
Under local anesthesia (20 ml of a 0.5% novocaine solution), the skin is dissected immediately below the navel along the midline for 1 cm in the transverse direction with a scalpel. The upper edge of the skin wound is sutured with silk thread No. 8 on the cutting needle and this thread is used as a holder, conically raising the portion of the anterior abdominal wall behind it. Due to the presence in the navel durable fibrous connected Nia skin aponeurosis stretching thread allows to lift and firmly fixed Vat aponeurosis. After a skin incision and subcutaneous tissue to the aponeurosis, fixed vannomu taped, fed trocar and its rotational movement is carried out in the abdominal cavity in a direction obliquely upwards and somewhat to the left. In this case a feeling of failure (aponeurosis can be pre-puncture tip scalp la). If after removing the stylet of a trocar tube from the abdominal cavity proceeding in a blood or exudate fluid, bile stained (intestinal contents), following is considered damage to internal organs established, no further manipulation tion thus superfluous. If there is no entry through the tube of the trocar from the abdominal cavity, a vinyl catheter should be inserted through it.
At the end, inserted into the abdominal cavity, the catheter for 10-15 cm should have numerous holes. The catheter is introduced over the entire length in the next subsequent successive: right and upwards (to the liver), the left and up (to the spleen), strictly to the left (in the left lateral channel), down and to the left (the pelvis) straight down (toward the urinary puzy Ryu), down and to the right (to the cecum and to the right lateral canal).
By introducing a catheter into the desired area, each time with it into the abdominal cavity of a syringe injected with 100 ml novocaine solution or isotonic sodium chloride solution, and after the solution was aspirated with the same syringe.
Detection of blood impurities intestinal contents, urine or turbid eq ssudata indicates damage to internal organs. Pink staining of the lavage fluid obtained from the lateral and lower parts of the stomach, mo Jette depend on the availability retroperitoneal hematoma blood propotevanie through back Nij sheet peritoneum. When equivocal research tube troa car is removed and the catheter is left in the abdomen. The outer end is fixed using a previously applied holder thread. Impose sterile hydrochloric bandage. The catheter can be in the abdominal cavity for up to two days. Shall be repeated diagnostic lavage abdominal Th Res day after paracentesis. If questionable data catheter axes may be Tavlya for repeated washings another day. The fluid obtained by aspiration through a catheter is sent to a laboratory for research on red blood cells, white blood cells, amylase.
Laparoscopy as an instrumental method is only used for diagnosis in some cases it can be used for Gemos pelvis (e.g., by surface liver damage). The use of laparoscopy allows you to visually inspect the abdominal cavity and otse thread degree of damage and thus finally solve the problem of no necessity laparotomy.
At the same time, as when performing laparocentesis (laparocentesis is the first and mandatory stage of laparoscopy), the correct conduct of laparoscopy and interpretation of the data obtained in this case requires some experience. Contraindications to paw ROSCOP is sharp bloating, rub the presence of multiple call centers in the anterior abdominal wall, as well as an extremely serious condition caused by a shock, chest injury, brain. It is a connection but that only if sufficient pneumoperitoneum (1.5-2 liters) can but thoroughly inspect all parts of the abdominal cavity and pneumoperitoneum this volume significantly affects not only the respiratory function, but also on hemodynamic parameters. The imposition of a large pneumoperitoneum is absolutely contraindicated in cases of suspected rupture of the diaphragm, because this will quickly lead to intense pneumothorax and death of the victim.
The introduction of a laparoscope trocar is carried out in the same way as with laparocentesis. After the introduction of the trocar, the stylet is removed and an optical tube is inserted, connected by a light guide to the illuminator. Pneumoperitoneum required for IP route, is applied by introducing air, oxygen, carbon dioxide or nitrous oxide, through a special crane on a trocar or abdominal cavity punktirujut further in the left iliac area special needle available in kit la paroskopa.
A detailed examination of the abdominal organs is achieved by changing the position of the patient on the operating table. When the position on the left side you can see the great vy side channel with a blind, ascending colon right half of the colon and liver. The oil seal in this position is shifted to the left side. When the patient is on the right side, the left lateral canal with the descending intestine becomes accessible.
Patients with concomitant injury position on the operating table would often Vaeth internally, making it difficult to detailed examination of the abdominal cavity.
In pelvic fractures, as a rule, large retroperitoneal and preperitoneal hematomas that bulge into the abdominal cavity are revealed. In rare cases, it is possible to examine an unexagined damaged spleen. The conclusion of her injury made by circumstantial evidence – wicking and accumulation of blood in the left latte eral channel.
Bleeding from a damaged liver is easier to detect, since most of this organ lends itself well to inspection. However, tears in the posterior surface of the liver are not visible. Break diagnosis in these cases is put on the basis of the accumulation of blood in the right- tion subhepatic space and the right lateral channel. Blood Level gras Nica pelvic indicates a sufficiently large blood loss (more than 0.5 L). The presence of blood only between the loops of the intestine can be with blood loss less than 03-0.5 liters. Light yellow fluid in the peritoneal cavity causes suspected of stated failures intraperitoneal part of the bladder. To clarify the diagnosis optionally go to enter into the cavity of the bladder solution of methylene blue. In case The appearance Lenia (5-10 minutes) of the colored solution in the abdomen diagnosis harmed Denia bladder wall becomes obvious. The presence of turbid fluid in the abdominal cavity makes intestinal damage suspected.