The end of XX and beginning of XXI century is characterized by a sharp increase in trauma -Semitism, which is associated with increasing traffic flows, high-rise construction and criminalization of society. Especially noticeable these ten Dentsu in major cities. With the exception of traumatic brain injury ab dominalnye damage are the most dangerous, because accompanied are a large number of complications, a high level of mortality and disability. The total mortality of victims with injuries of the abdomen with combined trauma reaches 60%. The first place in frequency is damaged Nij abdominal organs occupy parenchymal organs (ne ry, spleen, kidneys).
The effectiveness of medical care for any injury to a large extent depends on its organization, which is unthinkable without a clear classification of injuries.
Symptoms of Abdominal injury:
Classification should be simple and easy to practice at Menen, as well as provide an opportunity to choose its basis diagnostiches kuyu and treatment policy. Such requirements are met by classification stated failures is presented in the domestic doctrine martial chi rurgii. However, given the specificity of aid postradavshe mu civilians, this classification we made respectively stvuyuschie additions.
Damaging agent. Depending on what kind of energy for carrying harm to human body, the injury may be:
Mechanical – due to exposure to mechanical energy. The wasps novnom, it suffered from a mechanical trauma are objects that surgeons activities (various types of wounds, injuries from motor vehicle accidents, falls, etc.);
Heat – arises from the action of high (burns) or low (from ice cream) temperature. Assistance in this type of damage is done by combiologists;
Chemical – due to the contact with any of the plurality hee mical compounds. Strictly speaking, any chemical poisoning pre Paraty (including drugs) is a chemical injury. Od Nako surgeons deal with the consequences of such actions so called Mykh caustic fluids (acids and alkalis), organ necrosis pi schevaritelnogo tract or fibrous transformation of these bodies;
Radiation – due to exposure to radiation energy.
The combination of two or more types of energy that caused damage to the human body is called a combined injury. It is very important to remember this definition, as hitherto in many manuals term “combination trauma” is used as the sino them “associated trauma.” Of course, combination and combination alone mean the same thing. Moreover, in modern English-language medical literature, these two concepts are not separated. Meanwhile, such a confusion of concepts does not contribute to a quick orientation in the nature of the pathology, and, therefore, should not suit a practical doctor. Therefore follows blowing distinguish between these terms.
The prevalence (scale) of injury. To determine obe ma injury the whole body rather conditionally divided into 5 areas. Damage to each of them leads to specific methods of diagnos tics and treatment, and therefore each of them is engaged in a physician -boiling specialty. These areas are: 1) head (and yc Karlovna spine and spinal cord), 2) a neck, 3) chest, 4) stomach 5) musculoskeletal system (extremities and pelvis).
If the action of one of the above damaging Agen comrade was limited to only one area, we are talking about an isolated injury to this area (mechanical isolated abdominal injury at the example). If the action of the same agent caused damage to two or more areas of the body, we are talking about combined trauma (mechanical combined trauma to the chest and abdomen, for example). Since surgeons deal mainly with mechanical trauma, the definition of “mechanical” is usually omitted. In what follows, we consider only the classification of the IU -mechanical injury.
Characteristic of the injury. All mechanical damages are divided into from the indoor (injured) and closed. This subdivision injuries are camping no less important than the term “isolated”, “combined”, “combi nirovannoe”. The fact that public and private damage It lines pial differ from each other: the causes and severity, and diagnostic methods and treatments and, most importantly, outcomes. Therefore, these damage should be considered separately.
Injured. Absolute sign open trauma (wound) is a camping availability wounds (violation of the integrity of the skin, external slizis ies membranes). Wounding may be applied cold arms (Kin stings, knife, “grinding” as used in the criminal environment) or object E life employed as the cold arms (awl, a screwdriver, table forks, scissors, etc.) divided by the external Wounds type of wounds on chopped, chopped, chopped.
Appearance stab wounds extremely misleading, as the small size of the wound and the absence Corollary external bleeding create the impression of a light injury. However, there may be serious damage to the vital organs and major suck rows, so this kind of injury worthy of close attention. On against incised wounds inflicted by glancing blow are most dramatiches cue view due dissecting plurality of vessels and the subcutaneous dehiscence. However, they are rarely so deep as to damage internal organs (the exception was saber wounds of past times). One should note tit that most often the surgeon has to deal with stab wounds, which are the stab, i.e. combine signs of both a stabbed and a cut wound.
Chopped wounds were a fixture of the armed conflict about shlyh centuries (halberd, battle-ax, sword, broadsword), now rare, applied with an ax. Accompanied by greater tissue destruction, the nature of us more for the wounds of the head than the chest and abdomen.
A peculiar type of injury occurs when an arrow from a sporting bow, crossbow, and spear gun are used. Despite the long history of this type of weapon, such injuries in recent years began to meet again and wound Nana hay they can be accompanied by damage to vital organs.
Addition of knives, the wound can be deposited metallically E constructs and glass (classic example – car Av dence) and so-called secondary projectiles – flying at high velocity fragments of stones, bricks, glass fragments (for destroying SRI building during earthquakes time, for example). Such wounds are called torn-bruised and their feature is visible from the name. Finally, lacerations inflicted by dogs and wild animals represent a special variety .
Gunshot wounds are the most dangerous. Unlike various kinds injured cold arms, in which the wound channel length (and hence, destruction of tissue along its length) defines Xia localization skin wound and length wounding implements wound channel length and the degree of tissue destruction during gunshot wound depends on the kinetic energy of wounding projectile ( bullets, fractions, fragment), that is, the speed with which this shell penetrates the human body.
Direct action firearm projectile (bullet), and the resulting ne ed them waves compressed air causes tissue destruction in the course of wound Vågå channel with partial discharge razmozhzhennoy masses through the inlet and outlet openings. The bones lying on the path of the projectile are crushed with great force and, in the form of secondary shells, damage surrounding soft tissues.
The extent of tissue destruction during a gunshot wound is many times greater than the size of the projectile and the wound channel made by it. The large kinetic energy of the projectile leads to the formation of a so-called temporary pulsating cavity in the tissues, the pressure in which increases so quickly and so high that its occurrence is compared with an interstitial explosion. The dimensions of this cavity vary sharply depending on the density of the tissues; on average, they exceed the projectile caliber by 10 or more times. In the results are gunshot wound in tissues and organs distinguish three zones damage: the wound channel zone, primary traumatic necrosis zone (contusion) and secondary traumatic necrosis zone (molecular shaking).
Zone primary traumatic necrosis varies widely pre affairs and may take several centimeters. Immediately after a wound, it has the appearance of extensive hemorrhage, while tissue necrosis can clearly occur after a few hours or even days. This circum stances much more difficult to correct choice of primary hirur volume cal treatment for gunshot wounds and consequently made difficult nyaet predicting complications.
The zone of molecular concussion can be characterized as necrobiosis. It goes without sharp boundary in normal tissues, changes in it are reversible, but the confluence of unfavorable circum ments in the area of tissue necrosis occurs.
All gunshot wounds are divided into bullet, shot and fragmentation. Conventionally, they include wounds inflicted by a gas stream when fired from a gas pistol at close range.
Gunshot wounds inflicted by modern small arms, characterize camping most extensive destruction of organs and tissues. Multiple injuries from automatic weapons leave the victim little chance of life.
Multiple wounds are characteristic of fragments of exploding artillery shells or aircraft bombs. According to the American hirur gov, during “Operation Desert Storm” (the Persian Gulf, 1991), most shrapnel wounds were multiple and non-invasive. It should be replaced tit that in every armed conflict, depending on the specific situation, has its own peculiarities in the structure of sanitary losses, in other words – in the ratio of types of gunshot wounds.
A particular type of gunshot injury is a mine explosive injury. This type of lesion is found in the practice of a surgeon in recent years in providing assistance to victims of terrorist acts. The destructive force of an explosion depends on the power of the charge. In open space, it decreases with every meter from the place of the explosion, but in a closed room, even a small charge causes huge damage. Wherein the factors affecting, among fragments are camping flame effect (burns) and blast wave (barotrauma). Thus, with a mine explosion, a combined injury occurs.
All gunshot wounds are divided into blind and through. Wound schi thawed blind, when there is only an inlet (space entry projectile wounding), and the shell is wounding in the tissues. When through Mr. wounding wounding projectile forms not only input but also an outlet (wound “Bang Bang” in the terminology of the Great the Patriotic stvennoj war).
Typically, inlet dimensions correspond to the dimensions of the RA nyaschego projectile, while an outlet opening, especially when rds crystals at close range is much greater than the input, in the zone of greater destroyed tissues, more intense external bleeding. Those of circumstance to be considered when providing medical assistance at the scene.
Aligning localization inlet and outlet openings on whether the direct research institutes, can be very likely to present the progress of the wound channel and possible damage to the organs of the chest and abdomen. However, during their use SRI modern military weapons such patterns can not be, especially when using the bullets with an offset center of gravity.
The danger of any kind of injury increases dramatically if the wound ka cash enters the abdominal cavity. Therefore, all the injury is divided into non food Nick and penetrating. Non-penetrating wounds are less dangerous, however this is more true for wounds of the anterior abdominal wall.
Stab wounds (in the lumbar region), not to mention the fire Strelna, without penetrating into the abdominal cavity, can result in damaged niyamas kidney, pancreas, duodenum.
Even a superficial incision wounds but extensive damage to the set -OPERATION located subcutaneously blood vessels can lead to life-threatening blood loss, if assistance will not be provided timely.
No matter penetrates or does not penetrate into the wound in the serous of lethargy, all wounds are divided into two groups, with no damage internal organs new and damaged internal organs.
Experience has shown that 15-20% of the total number of observations penetrating constituents stab wounds abdomen organ damage is not observed, despite the fact that there is damage to the parietal layer of the peritoneum, ie It may be harmed penetrating damage without providing internal organs. Gunshot wounds such cases, WHO is possible, but they can be considered casuistry. Non-penetrating wounds, as mentioned above, can also be accompanied by damage inside their bodies.
In wounds abdomen distinguish damage parenchymatous organs newly (liver, spleen, pancreas, kidney), the hollow bodies (same ludochno tract, gall bladder, urinary bladder) and vessels (aorta, inferior vena cava and portal vein, mesenteric vessels).
The division of authorities at the parenchymal hollow and is of fundamental importance not only because of the morphology of the lesions, but because of the Various Chii in symptoms, methods of surgical treatment, the occurrence and those chenii complications. If damage parenchymatous organs lead boiling pathology is a massive blood loss, then wound hollow op ganas digestive tract and bladder – factor massive infections (abdominal cavity and retroperitoneal space).
There are many proposals on the classification of wounds Mrs. Vaught. The most appropriate of them will be discussed below in the sections on the treatment of organ damage, since one of the main objectives of creating a classification – determination on the basis of its tactics leche Niya. The general principles of these classifications are as division of stated failures parenchymal organs at:
1) superficial wounds of an organ capsule; 2) wounds of the capsule and parenchyma, not reaching the area of the vascular secretory leg of the organ; 3) wound with the capsule and parenchymal damage vascular secretory orga legs on; 4) razmozhzhenie (at gunshot wound) or cut off (for pa nenii cold steel) part of the organ.
All classifications of wounds of hollow organs can also be reduced to a single principle: 1) wounds of the serous membrane; 2) injury to the pro body light; 3) through wounds; 4) the crushing or crossing of an organ.
When injuring hollow organs, the localization of the wound is of great importance – whether it has an intraperitoneal location or extraperitoneal.
There is a noticeable difference in the difficulties of diagnosis, treatment and the outcome of the injury, depending on how many organs are damaged and how many wounds this or that organ has. Damage to one organ is called a single injury (for example, the victim has a stab wound to the abdomen with two liver wounds, hemoperitoneum, no other injuries).
If the damaged organ has a wound, such damage should be called monofocal, if you have multiple wounds, then – polifokal nym. (In the foregoing example, we are dealing with a single Poliphili Kalnoy injury, as there are several liver wounds).
Damage to several organs is called multiple trauma (bullet wound to the stomach, spleen and left bend of the colon, for example).
Among the combined wounds of the chest and abdomen, thoracoabdominal, abdominothoracic wounds and simultaneous wounds of the chest and abdomen should be distinguished.
Closed injury. In patients with a closed injury, exposure to mechanical energy leads to damage to internal organs and tissues without damaging the skin.
Closed damage stomach is divided by the damage (bruises) bryush hydrochloric wall damage internal organs of the abdominal cavity and retroperitoneal space. Naturally, the damage to internal organs is new are the most difficult and dangerous.
As with injuries, with a closed abdominal injury, damage to parenchymal, hollow organs and large blood vessels is distinguished. Retroperitoneal hematoma is especially distinguished.
Retroperitoneal hematoma (more correctly, retroperitoneal hemorrhage) occurs with fractures of the bones of the pelvis, spine, and rupture of retroperitoneal organs and blood vessels. It is most often observed when falling from a height and with an accident. Distinguish between unilateral and dvusto eral hematoma.
Depending on the prevalence, retroperitoneal hematomas can hold from 500 to 3000 ml of blood. In particular, if the hematoma is limited to the pelvic cavity, its estimated volume is 500 ml; if the hematoma reaches on both sides of the lower poles of the kidneys, then its volume is at least 1.5 l; when reaching the upper poles -2 l; when distributed to the diaphragm – 3 liters. With hemorrhage more than 2 liters of hematoma spreads to the prebubble space and preperitoneal tissue.
In such cases, often part of the blood (200-300 ml) was exuded through the sheet Bru tire in free peritoneal cavity, which is accompanied by a corresponding clinical cal picture and may cause undue laparotomy. At the same time, be aware that there are cases of retroperitoneal hematoma breaking hard into the abdomen with ongoing bleeding that requires Nemedia lennoy laparotomy.
In addition, with massive hemorrhage, blood can spread through the intermuscular spaces and cellular spaces to the lumbar region, buttocks, perineum and inner thighs. It is clear that such a large amount of blood loss in itself can cause death.
The blood which flowed into the retroperitoneal space, infiltrates the fiber, irritation zhaet large number of nerve receptors and celiac lumbosacral wreath product plants, is that causes for a long traumatic shock resistant and paresis of the gastrointestinal tract. After 5-6 days of paresis of the gastrointestinal tract nachi naet resolved, but at the same time begins to increase endotoxemia caused by absorption of the products of decay streamed blood. Clinically this translates into length tion icterus, which can lead to renal failure.
Among closed injuries parenchymatous organs distinguished: on -surface (depth of not more than 3 cm for the liver, spleen to 1 cm, Poggio ludochnoy gland and kidney) ruptures; deep discontinuities (more vysheozna chennoy depth); central gaps passing through the goal area; subcapsular hematoma (torn peripheral body sections with preservation nennoy capsule); intrahepatic hematoma (discontinuities parenchyma with storage capsule); separation or softening of the whole organ or its part.
An example of a successful clinical and morphological classification is a classification fication of liver damage, adopted by grass Surgeons American Association matologov in 1986 and revised in 1996. It takes into account not only of morphological Gia injuries and closed injuries, but also the dynamics of the damage, not nuzh Giving in surgical treatment. In this classification has combined with signs of both open and closed injuries.