Knife wound to the lung with consequences. Open chest injuries. Causes of injury

Emergency measures consist primarily of decompression pleural cavity or mediastinum with tension pneumothorax or pneumomediastinum, hermetic closure of a chest wound with open pneumothorax, correction of hypoxia and hypovolemia, replenishment of blood loss.

Minor wounds chest wall, especially in those areas where there are powerful muscle layers, do not require treatment and heal well under the scab. Wounds with a large area of ​​damage should be carefully treated and sutured in layers to avoid suppuration and the occurrence of secondary pneumothorax.

Surgical tactics are determined by the characteristics of pneumothorax and hemothorax. Treatment should begin with puncture of the pleural cavity. For air aspiration, it is advisable to perform it in the second intercostal space along the midclavicular line, and to remove blood in the seventh-eighth intercostal space - along the posterior axillary line in order to avoid puncture of the thoraco-abdominal obstruction. Indicators of the effectiveness of puncture are possibly complete removal blood and creating a vacuum in the pleural cavity with expansion of the lung.

Subsequent treatment is carried out under careful x-ray control; If air and fluid are detected in the pleural cavity, repeated punctures are indicated. If the vacuum is unstable and there is no tendency to expand the lung, the introduction of intercostal drainage is indicated. Depending on the severity of air blowing through the drainage, it may be necessary to introduce two or even three drainages. Continued tension of the pneumothorax and mediastinal emphysema, blowing a large amount of air, despite actively functioning drainages, are indications for thoracotomy.

If it is possible to eliminate tension in the pleural cavity, but blowing persists, then on the first day you can temporarily refrain from active aspiration and limit yourself to valve drainage according to Petrov-Bülau. Aspiration mode - before “gluing” the edges of the lung wound in the first days, the vacuum should be 15-20 cm of water. Art., a large degree of rarefaction can lead to ex vacue hemorrhage and prevent the closure of the lung wound by the falling fibrin. J. Richter (1969) recommends achieving complete expansion of the lung within 8 days. According to our data, the lack of effect from aspiration within 3-4 days should be considered an indication for thoracotomy.

The second indication should be considered ongoing intrapleural bleeding, detected by puncture and the Rouvilois-Gregoire test. This approach to the treatment of lung injuries is used by most surgeons [Tsybulyak G.N., Vavilin V.A., 1977; Richardson T.D., 1978, etc.].

Careful weighing of the indications for surgery, skillful use of conservative measures and X-ray control can significantly reduce the number of thoracotomies for lung injuries.

The method of choosing access for thoracotomy in case of lung injury should be considered a standard lateral incision along the fifth-sixth intercostal space and along the seventh intercostal space if damage to the diaphragm is suspected. Standard thoracotomy with the patient positioned on the healthy side is low-traumatic and makes it possible to examine in detail and perform the necessary manipulations on the lung, its root and in all parts of the corresponding pleural cavity.

We emphasize once again that attempts to perform a thoracotomy by expanding the chest wound can end tragically: inconvenience is created during manipulation in the pleural cavity, combined injuries are visible, the edges of the chest wound are injured and suppuration occurs. After opening the pleural cavity and spreading the edges of the wound, the blood accumulated in the cavity is removed and used for reinfusion. Then the lung, mediastinum, and diaphragm are examined.

In the circumference of a stab wound of the lung, as a rule, there are no massive hemorrhages. Its edges are often smooth, and when you inhale, they diverge and allow air to pass through. If the peripheral zone of the lung is damaged, the wound is usually filled with bloody foam. In such cases, it is enough to apply several interrupted sutures using thin silk, nylon or lavsan threads. They should not be tightened too much, as the lung tissue is easily cut through. It is advisable to use thin round (preferably atraumatic) needles. Cutting needles, especially thick ones, are not suitable for this purpose. Good sealing is achieved by applying a thin layer of cyanoacrylic adhesive over the seam.

Superficial lung wounds do not need to be sutured. Having grabbed the damaged area with a clamp and slightly tightened it, apply a regular ligature.

Small caliber bronchi are sutured and tied with silk thread. Interrupted sutures are placed on slot wounds of larger bronchi. Maintaining patency when suturing the crossed bronchi is an important condition for the success of the operation. Their ends are carefully sewn together with atraumatic needles charged with nylon, lavsan, chrome-plated catgut or supramid. Narrowing of the bronchial lumen leads to hypoventilation or atelectasis of the corresponding part of the lung.

Surgical tactics for deep lung wounds have some features. R. P. Askerkhanov and M. I.-R. Shakhshaev (1972) rightly note that superficial sealing of such wounds does not prevent the formation of intrapulmonary hematomas, which can subsequently become abscesses. Deep wounds of the lung, after preliminary ligation of damaged vessels and small bronchi, are sutured with 8-shaped sutures drawn to the bottom of the wound.

When suturing the lung, the UKL-40, UKL-60 devices are widely used, as well as the UO-40 and UO-60 suturing devices for applying linear two-line staggered sutures with tantalum staples. Thanks to this, it is possible to significantly reduce the duration of the intervention.

Processing torn lung wound, in particular in case of gunshot wounds of the chest or closed injury, all crushed tissues are removed and, depending on the degree of destruction, wedge-shaped resection, removal of a segment, lobe of the lung, and even the entire lung are resorted to.

Patient D., 30 years old, was delivered in extremely serious condition 1 hour after drunkenness shot himself in the left half chest from a shotgun. Blood pressure 80/40 mm Hg. Art., pulse 100 per minute, weak filling. Sharp pallor skin. On the left, on the front wall of the chest, 2 cm below the nipple, there is a gunshot wound measuring 3x3 cm with burnt edges. She is bleeding profusely. Breath sounds on the left side cannot be heard.

Infusion of fluid into two veins. Thoracotomy under endotracheal anesthesia. About 1 liter was found in the pleural cavity liquid blood, which is collected for reinfusion; in the lingular and lower lobes of the lung in the root area there is a through wound.

Due to extensive injuries and ongoing bleeding, they were resected using UKL-40 and UKL-60 devices. A felt wad and pellets were removed from the chest wall wound. Fragments of the VIII rib were resected. Drainage was introduced into the pleural cavity. The chest wall wound is sutured. The postoperative period was complicated by pleural empyema. Recovery has come.

When deciding to remove damaged areas of the lung, the surgeon should do this as sparingly as possible to ensure maximum recovery. respiratory function. IN in some cases severely injured segments have to be preserved. An example would be successful cost-effective intervention for wounds. lung tissue and lobar bronchus in a patient with severe bronchiectasis.

Patient P., 23 years old, was delivered 40 minutes after being injured on the right side of the chest when falling on a metal part. Extensive soft tissue defect of the chest wall. This area floats due to a fracture of the 5th and 6th ribs along the scapular and mid-axillary lines on the right. Shortness of breath, pallor, cyanosis of the lips, pulse 118 per minute, blood pressure 80/50 mm Hg. Art. A vagosympathetic blockade was made on the right, and 2 ml of a 2% promedol solution was administered.

During the operation under endotracheal anesthesia, an extensive rupture of the lower lobe leading to the root was discovered. A fragment of a rib was inserted into the lung wound, damaging the lower lobe bronchus for 1 cm. They decided to preserve the lobe, taking into account that the left lung was affected by bronchiectasis (shortly before the injury, the patient was examined for the purpose of resection of this lung).

Interrupted sutures were placed on the wound of the lobar bronchus, capturing the lung tissue. Damaged bronchi of smaller caliber are chipped and bandaged; the wound is closed with additional interrupted catgut sutures. Using the UKL-60 device, the crushed edge of the lobe was resected. When the pressure in the anesthesia machine increases, the wounded lobe is well inflated, a fragment of the 5th rib is removed, and the edges of the fragments of the 5th and 6th ribs are processed. After the administration of antibiotics and excision of the torn edges of the skin wound, the pleural cavity is sutured tightly in layers. Drainage was introduced through the eighth intercostal space. The postoperative period proceeded without complications.

Surgical intervention becomes more difficult if the bronchial wound has uneven edges or significant damage to its wall is detected. In such cases, the damaged portion of the bronchus is resected and an anastomosis is performed. To cover the anastomosis line, you can use the pleura, pericardium, and lung.

Patient P., 26 years old, was admitted 2 hours after a bilateral chest wound. The condition is extremely serious, bilateral valve pneumothorax. Severe suffocation and extensive, rapidly growing subcutaneous emphysema.

X-ray revealed that right lung completely pressed to the root, the left one is collapsed to 2/3. Pneumothorax is accompanied by mediastinal emphysema. The pleural cavity on the left was punctured. Only by constantly sucking out the air is it possible to maintain the lung in a straightened state. The pleural cavity is drained, active aspiration is installed.

Right thoracotomy under endotracheal anesthesia. The lung is collapsed, the insufflated gas freely exits through a defect of the upper lobe bronchus measuring 0.5x1 cm with uneven edges. Wedge-shaped excision of the damaged area of ​​the bronchus; its ends are connected with interrupted silk sutures, and the edge of the lung is hemmed to the suture line. After restoration of patency bronchus lung managed to straighten it completely. The patient's condition began to improve quickly, postoperative period proceeded without complications.

Damage to large main vessels due to injuries to the root of the lung is accompanied by massive bleeding. According to our observations, damage to the side wall of the root vessels is more common, rather than their complete intersection, which sometimes makes it possible to stop fatal bleeding by applying sutures. Unfortunately, most of these wounded people die before they can be transported to a hospital.

At the end of the manipulations on the lung, the pleural cavity is freed from residual blood and accumulated fluid using wet wipes or aspiration; Antibiotics are injected into the pleural cavity. After a small intervention, when there is no reason to fear the accumulation of air or exudate, they are limited to introducing drainage through the eighth intercostal space. If the injury was significant and the operation was complex, then two drains have to be installed: through the eighth and second intercostal spaces. Contusional lung injuries in themselves usually do not pose a direct threat to the victim’s ulceration. The main task in their treatment is the active prevention of atelectasis, edema, pneumonia and abscess formation.

The first priority in restoring normal breathing is to ensure sufficient chest excursions. For this purpose, cervical vagosympathetic blockade and, in the presence of rib fractures, anesthesia of fracture sites or epidural anesthesia are indicated. Then normal ventilation in the damaged area should be restored. lung area. When coughing is difficult, aspiration of mucus from the trachea and bronchi with a nasotracheal catheter is very effective. Great importance we attach microtracheostomy. If there is no effect, therapeutic bronchoscopy is performed.

With atelectasis, all attention is focused on restoring bronchial patency, activating the patient and preventing inflammatory complications.

Therapeutic measures for “wet” lung give good results only when applied early. They boil down to ensuring good aeration, oxygen inhalation, novocaine blockades, in some cases - tracheostomy and mechanical ventilation, dehydration therapy.

To prevent inflammatory processes and secondary atelectasis, the following set of measures is used:
1) repeated blockade of fracture sites, cervical vagosympathetic according to A. V. Vishnevsky or blockade of the stellate ganglion according to Minkin; 2) breathing exercises, exhalation with slight resistance (inflating rubber circles, bags); 3) antibacterial therapy and administration of proteolytic enzymes parenterally and endotracheally; 4) cardiovascular therapy according to indications; 5) oxygen inhalation.

The patient should be placed on a functional bed in a semi-sitting position.

Thus, in case of lung damage surgery taken with ongoing massive bleeding, intractable hypertensive pneumothorax and mediastinal emphysema, as well as with deterioration of the condition caused by lung injury. According to our data, the need for thoracotomy for lung injuries with penetrating wounds occurs in 48.5%, and with closed trauma - in 2.4% of victims.

Classification. There are closed and open lung injuries.

Closed lung injuries: 1. Lung contusion. 2. lung rupture. 3. crushed lung. Lung ruptures can be single or multiple, and in shape - linear, polygonal, patchwork.

There are open injuries (wounds) of the lung: stab wounds and gunshot wounds.

A.V. Melnikov and B.E. Linberg distinguish three zones of the lung: dangerous, threatened, safe.

The danger zone is the root of the lung and the hilar area, where large vessels and bronchi of the 1st and 2nd order pass. Damage to this area is accompanied by profuse bleeding and tension pneumothorax.

The threatened zone is the central part of the lung. Segmental bronchi and vessels pass through here.

The safe zone is the so-called lung cloak. Includes the peripheral part of the lung, where small vessels and bronchioles pass.

Lung contusion

Lung contusion is damage to lung tissue while maintaining the integrity of the visceral pleura. Lung contusions are divided into limited and extensive.

Pathanatomy: in the area of ​​the bruise there is hemorrhagic penetration of the lung parenchyma without sharp boundaries, destruction of the interalveolar septa. There may be destruction of lung tissue, bronchi, and blood vessels with the formation of a cavity filled with air and blood in the lung. When a lung is contused, atelectasis, pneumonia, and an air cyst of the lung develop.

The clinical picture depends on the size of the area of ​​lung damage.

With limited bruises of the lungs, the victim’s condition is satisfactory, less often - moderate severity. There is pain at the site of injury, shortness of breath, cough, and hemoptysis. Blood pressure is not changed, the pulse is slightly increased. On auscultation, there is a weakening of respiratory sounds over the site of the injury with the presence of moist rales. Percussion sound is dull. On a survey radiograph: in the pulmonary field, an oval or spherical darkened area with indistinct, blurry contours is visible.

With extensive bruises of the lungs, the patient’s condition is moderate or severe. The victims are admitted in a state of shock and severe respiratory failure with shortness of breath up to 40 breaths per minute, cyanosis of the facial skin, blood pressure is reduced, and tachycardia reaches high numbers. Auscultation of breathing on the injured side is sharply weakened, with moist rales.

Diagnostics. 1. Clinic. 2. Survey fluoroscopy (graphy) of the chest. 3. Tomography. 4. Bronchoscopy. 5. Computed tomography.

Treatment: 1. Relief of pain syndrome (novocaine blockades, analgesics). 2. Antibacterial therapy. 3. Vascular therapy. 4. Restoration of normal drainage function of the bronchi. 5. Breathing exercises. 6. Physiotherapy.

Clinically and radiologically, lung contusions occur in 2 scenarios: 1. With adequate conservative treatment, the process is completely stopped after 10 days.

2. The so-called post-traumatic pneumonia, which can be treated conservatively within 10-14 days or a lung abscess develops.

Wounds and ruptures of the lung

Lung injuries in which lung tissue and visceral pleura are damaged. Blood and air enter the pleural cavity.

Characteristic signs of lung damage: 1. Pneumothorax. 2. Subcutaneous emphysema. 3. Hemothorax. 4. Hemoptysis.

All victims with closed lung injuries are divided into the following groups:

1. with pneumothorax; 2. with valve pneumothorax; 3. with hemothorax.

For open lung injuries, another group is added - with open pneumothorax.

Clinic: 1. General symptoms damage. 2. Specific symptoms.

Common symptoms include: pain, signs of bleeding, shock, respiratory failure. Specific symptoms include: pneumothorax, hemothorax, subcutaneous emphysema, hemoptysis.

Diagnostics: 1.Clinic. 2. Plain radiography (scopy) of the chest. 3. Ultrasound of the chest. 4. Pleural puncture. 5. thoracoscopy 6. Pho wound.

Treatment: General principles of treatment depend on the type and severity of the lung rupture or wound. They include: elimination of pain, early and complete drainage of the pleural cavity for the purpose of rapid expansion of the lung, effective maintenance of airway patency, sealing of the chest wall for open injuries, antimicrobial and supportive therapy.

If the lung is damaged with an open pneumothorax, first of all, the wound is pierced, the open pneumothorax is sutured and the pleural cavity is drained. The vacuum mode during aspiration for gluing the edges of a lung wound is 15-20 cm of water column.

If the lung is damaged with a small hemothorax, a puncture of the pleural cavity is performed and blood is removed from the sinus. For moderate hemothorax, drainage of the pleural cavity with blood reinfusion is indicated.

Indications for thoracotomy for lung injuries:

1. Profuse intrapleural bleeding. 2. Continued intrapleural bleeding - if 300 ml of blood per hour or more is released through the drainage, with a positive Ruvilois-Gregoire test. 3. Intractable conservative tension pneumothorax.

Operative access for lung injury is lateral thoracotomy in the 5-6 intercostal space.

Operational tactics: For superficial wounds or damage to the peripheral zone of the lung, interrupted sutures are applied. For this, thin silk, nylon or lavsan threads are used.

For deep wounds of the lung: the wound channel is inspected, with the removal of blood clots and foreign bodies. If necessary, the lung tissue is dissected above the wound channel. During the revision, damaged vessels and small bronchi are sutured and bandaged. Particular care is taken to inspect wounds at the root of the lung. A deep lung wound must be sutured tightly, without leaving dead spaces. To achieve this, the wound is sutured to its full depth with one thread or several rows of sutures. For stitching, a round, large, steeply curved needle is used.

With extensive destruction of the edge of the lung, wedge-shaped atypical resection is indicated. The lung, within the healthy tissue, is sutured twice with a UKL apparatus.

If lung tissue is crushed within one or more segments, resection of one or more segments is performed. In case of massive destruction of lung tissue within one lobe, a lobectomy is performed. If the entire lung is destroyed or its root is damaged, a pneumonectomy is indicated.

After the intervention on the lung is completed, the pleural cavity is freed from blood clots and pleural drainage is installed according to Bulau. Before suturing a thoracotomy wound, it is necessary to ensure that the lung or its remaining part is fully expanded.

Damage to the trachea and bronchi.

Classification: distinguish between closed and open injuries of the trachea and bronchi.

Depending on the depth of damage, there are incomplete (damage to the mucous membrane or cartilage) and complete (penetrating into the lumen). Complete ruptures can occur with separation of the ends of the bronchi and without separation. Damage to the bronchi is extremely rarely isolated. More often, the lungs, mediastinum, and large vessels are simultaneously damaged. Damage to the trachea occurs due to knife and gunshot wounds to the neck.

Clinic: depends on the location and extent of damage.

Characteristic signs: 1. Emphysema of the mediastinum. 2. Subcutaneous emphysema. 3. Hemoptysis. 4. Tension pneumothorax. 5. Wound on the neck, communicating with the trachea.

With all types of damage to the trachea and bronchi, ventilation disturbances occur with severe respiratory failure. Sometimes asphyxia develops.

With open injuries to the trachea, air mixed with blood whistles out of the neck wound.

With combined injuries of the trachea and bronchi, signs of shock, blood loss, and respiratory failure come to the fore.

Diagnostics: 1. Clinic. 2. Plain radiography of the chest. The main radiological signs of bronchial damage are: mediastinal emphysema, pneumothorax, pulmonary atelectasis, subcutaneous emphysema. 3. Bronchoscopy. 4. thoracoscopy 5. computed tomography. It is imperative to examine the esophagus. Indirect signs of bronchial damage are: excessive release of air through the pleural drainage, ineffective drainage of the pleural cavity, collapse of the lobe or lung against the background of pleural drainage, increasing mediastinal emphysema.

Treatment: The main task of the preoperative period is to ensure and maintain airway patency. For mediastinal emphysema, a cervical mediastinotomy is performed. In case of tension pneumothorax, pleural drainage is installed in the 2nd intercostal space. If damage to the bronchus or thoracic trachea is suspected or a diagnosis of bronchial damage has been established, an urgent thoracotomy is indicated. The most convenient is the lateral approach. In case of isolated damage to the thoracic trachea, a longitudinal or longitudinal-transverse sternotomy is performed.

ABOUT

operative tactics: There are the following types of operations for damage to the bronchi: 1. suturing the wound defect; 2. excision of the edges of the defect, wedge-shaped or circular resection with restoration of lumen patency; 3. end-to-end anastomosis when the bronchus is separated; 4. lobectomy or pneumonectomy.

Indications for suturing are small wounds and defects. For lacerated and bruised wounds, the edges of the wound are excised to restore bronchial patency. Indications for pneumonectomy: significant destruction of lung tissue, inability to restore bronchial patency, damage to the vessels of the lung root.

– lung injuries accompanied by anatomical or functional disorders. Lung injuries vary in etiology, severity, clinical manifestations and consequences. Typical signs lung injuries include sharp chest pain, subcutaneous emphysema, shortness of breath, hemoptysis, pulmonary or intrapleural bleeding. Lung injuries are diagnosed using chest x-ray, tomography, bronchoscopy, pleural puncture, and diagnostic thoracoscopy. Tactics for eliminating lung damage vary from conservative measures (blockades, physiotherapy, exercise therapy) to surgical intervention(suturing the wound, resection of the lung, etc.).

Lung damage is a violation of the integrity or function of the lungs, caused by exposure to mechanical or physical factors and accompanied by respiratory and circulatory disorders. The prevalence of lung injuries is extremely high, which is associated, first of all, with the high frequency of thoracic trauma in the structure of peacetime injuries. This group of injuries has high rates of mortality, long-term disability, and disability. Lung injuries due to chest injuries occur in 80% of cases and are 2 times more likely to be recognized at autopsies than during the patient’s lifetime. Diagnosis problem and therapeutic tactics in case of lung injuries remains complex and relevant for traumatology and thoracic surgery.

Classification of lung injuries

It is generally accepted to divide all lung injuries into closed (with the absence of a chest wall defect) and open (with the presence of a wound opening). The group of closed lung injuries includes:

• lung contusions (limited and extensive)
• lung ruptures (single, multiple; linear, patchwork, polygonal)
• crushed lung

Open lung injuries are accompanied by a violation of the integrity of the parietal, visceral pleura and chest. According to the type of wounding weapon, they are divided into stab and gunshot weapons. Lung injuries can occur with closed, open or valve pneumothorax, with hemothorax, with hemopneumothorax, with rupture of the trachea and bronchi, with or without mediastinal emphysema. Lung injuries may be accompanied by fractures of the ribs and other bones of the chest; be isolated or combined with injuries to the abdomen, head, limbs, and pelvis.

To assess the severity of damage to the lung, it is customary to distinguish between safe, threatened and danger zone. The concept of a “safe zone” includes the periphery of the lungs with small vessels and bronchioles (the so-called “cloak of the lung”). The central zone of the lung with the segmental bronchi and vessels located in it is considered “threatened.” Dangerous for injuries is the hilar zone and the root of the lung, including the bronchi of the first and second order and great vessels- damage to this area of ​​the lung leads to the development of tension pneumothorax and profuse bleeding.

The post-traumatic period following lung injury is divided into acute (first day), subacute (second-third day), long-term (fourth-fifth day) and late (starting from the sixth day, etc.). The highest mortality is observed in the acute and subacute periods, while the distant and late periods are dangerous due to the development of infectious complications.

Causes of lung damage

Closed lung injuries can result from an impact with a hard surface, compression of the chest, or exposure to a blast wave. The most common circumstances in which people receive such injuries are road traffic accidents, unsuccessful falls on the chest or back, blows to the chest with blunt objects, falling under rubble as a result of collapses, etc. Open injuries are usually associated with penetrating wounds to the chest knife, arrow, sharpening, military or hunting weapon, shell fragments.

Except traumatic injuries lungs, they may be damaged by physical factors, for example, ionizing radiation. Radiation damage to the lungs usually occurs in patients receiving radiation therapy for cancer of the esophagus, lungs, and breast. The areas of lung tissue damage in this case topographically correspond to the irradiation fields used.

Lung damage can be caused by diseases that cause weakened lung tissue to rupture when coughing or physical effort. In some cases, the traumatic agent is foreign bodies of the bronchi, which can cause perforation of the bronchial wall. Another type of injury that deserves special mention is ventilator-induced lung injury, which occurs in patients receiving mechanical ventilation. These injuries can be caused by oxygen toxicity, volutrauma, barotrauma, atelectotrauma, and biotrauma.

Symptoms of lung damage

Closed lung injuries

A bruise or contusion of the lung occurs when strong impact or compression of the chest in the absence of damage to the visceral pleura. Depending on the strength of the mechanical impact, such injuries can occur with intrapulmonary hemorrhages of varying volumes, bronchial rupture and crushing of the lung.

Minor bruises often go unrecognized; more severe ones are accompanied by hemoptysis, pain when breathing, tachycardia, and shortness of breath. During examination, hematomas of the soft tissues of the chest wall are often detected. In the case of extensive hemorrhagic infiltration of the lung tissue or crushing of the lung, shock and respiratory distress syndrome occur. Complications of a lung contusion can include post-traumatic pneumonia, atelectasis, air lung cysts. Hematomas in the lung tissue usually resolve within a few weeks, but if they become infected, a lung abscess can form.

Lung rupture includes injuries accompanied by injury to the pulmonary parenchyma and visceral pleura. “Companions” of a lung rupture are pneumothorax, hemothorax, cough with bloody sputum, and subcutaneous emphysema. A bronchial rupture may indicate state of shock patient, subcutaneous and mediastinal emphysema, hemoptysis, tension pneumothorax, severe respiratory failure.

Open lung injuries

The uniqueness of the clinic of open lung injuries is due to bleeding, pneumothorax (closed, open, valve) and subcutaneous emphysema. Blood loss results in pale skin, cold sweat, tachycardia, drop in blood pressure. Signs of respiratory failure caused by a collapsed lung include difficulty breathing, cyanosis, and pleuropulmonary shock. With an open pneumothorax, during breathing, air enters and leaves the pleural cavity with a characteristic “squelching” sound.

Traumatic emphysema develops as a result of air infiltration of the periwound subcutaneous tissue. It is recognized by a characteristic crunch that occurs when pressure is applied to the skin, an increase in the volume of soft tissues of the face, neck, chest, and sometimes the entire torso. Particularly dangerous is the penetration of air into the mediastinal tissue, which can cause compression mediastinal syndrome, deep violations breathing and blood circulation.

IN late period penetrating lung injuries are complicated by suppuration of the wound canal, bronchial fistulas, pleural empyema, pulmonary abscess, gangrene of the lung. The death of patients can occur from acute blood loss, asphyxia and infectious complications.

Ventilator-induced lung injury

Barotrauma in intubated patients occurs due to rupture of lung or bronchi tissue during mechanical ventilation with high pressure. This condition may be accompanied by the development of subcutaneous emphysema, pneumothorax, lung collapse, mediastinal emphysema, air embolism and a threat to the patient’s life.

The mechanism of volumatic trauma is based not on rupture, but on overstretching of the lung tissue, which entails an increase in the permeability of the alveolar-capillary membranes with the occurrence of non-cardiogenic pulmonary edema. Atelectotrauma is the result of impaired evacuation of bronchial secretions, as well as secondary inflammatory processes. Due to a decrease in the elastic properties of the lungs, on exhalation, the alveoli collapse, and on inhalation, they become unstuck. The consequences of such lung damage can be alveolitis, necrotizing bronchiolitis and other pneumopathy.

Biotrauma is lung damage caused by increased production of systemic inflammatory response factors. Biotrauma can occur with sepsis, disseminated intravascular coagulation syndrome, traumatic shock, syndrome prolonged compression and others severe conditions X. The release of these substances not only damages the lungs, but also causes multiple organ failure.

Radiation damage to the lungs

Radiation damage to the lungs occurs as pneumonia (pulmonitis) with the subsequent development of post-radiation pneumofibrosis and pneumosclerosis. Depending on the period of development, they may be early (up to 3 months from the beginning) radiation treatment) and late (after 3 months and later).

Radiation pneumonia is characterized by fever, weakness, and expiratory shortness of breath varying degrees severity, cough. Typical complaints are chest pain that occurs during forced inhalation. Radiation damage to the lungs should be differentiated from metastases to the lung, bacterial pneumonia, fungal pneumonia, tuberculosis.

Depending on the severity of respiratory disorders, there are 4 degrees of severity of radiation damage to the lungs:

1 — a slight dry cough or shortness of breath on exertion is bothering you;

2 – a constant hacking cough is bothering you, the relief of which requires the use of antitussive drugs; shortness of breath occurs with slight exertion;

3 – a debilitating cough is bothersome, which is not relieved by antitussive drugs, shortness of breath is pronounced at rest, the patient requires periodic oxygen support and the use of glucocorticosteroids;

4 – severe respiratory failure develops, requiring constant oxygen therapy or mechanical ventilation.

Diagnosis of lung damage

Possible lung injury may indicate external signs injuries: the presence of hematomas, wounds in the chest area, external bleeding, air suction through the wound channel, etc. Physical data vary depending on the type of injury, but most often a weakening of breathing is determined on the side of the affected lung.

For correct assessment the nature of the damage requires a chest x-ray in two projections. X-ray examination allows you to identify mediastinal displacement and lung collapse (with hemo- and pneumothorax), spotty focal shadows and atelectasis (with lung contusions), pneumatocele (with rupture of small bronchi), mediastinal emphysema (with rupture of large bronchi) and others characteristic features various damages lungs. If the patient's condition allows and technical capabilities, it is desirable to clarify the X-ray data using computed tomography.

Bronchoscopy is especially informative for identifying and localizing bronchial rupture, detecting the source of bleeding, foreign body etc. Upon receipt of data indicating the presence of air or blood in the pleural cavity (based on the results of fluoroscopy of the lungs, ultrasound of the pleural cavity), therapeutic and diagnostic testing can be performed pleural puncture. In case of combined injuries, additional studies are often required: plain radiography organs abdominal cavity, ribs, sternum, fluoroscopy of the esophagus with barium suspension, etc.

In case of unspecified nature and extent of lung damage, diagnostic thoracoscopy, mediastinoscopy or thoracotomy are resorted to. At the diagnostic stage, a patient with lung damage should be examined by a thoracic surgeon and traumatologist.

Treatment and prognosis of lung injuries

Tactical approaches to the treatment of lung injuries depend on the type and nature of the injury, associated injuries, and the severity of respiratory and hemodynamic disorders. In all cases, hospitalization of patients is necessary specialized department to conduct a comprehensive examination and dynamic observation. In order to eliminate the phenomena of respiratory failure, patients are advised to supply humidified oxygen; in case of severe gas exchange disorders, a transition to mechanical ventilation is carried out. If necessary, anti-shock therapy and replacement of blood loss (transfusion of blood substitutes, blood transfusion) are carried out.

For lung contusions, it is usually limited conservative treatment: adequate pain relief is performed (analgesics, alcohol-novocaine blockades), bronchoscopic sanitation of the respiratory tract to remove sputum and blood, breathing exercises are recommended. In order to prevent suppurative complications, antibiotic therapy is prescribed. Physiotherapeutic methods are used to quickly resolve ecchymoses and hematomas.

In case of lung injuries accompanied by hemopneumothorax, the first priority is aspiration of air/blood and lung expansion through therapeutic thoracentesis or drainage of the pleural cavity. In case of damage to the bronchi and large vessels If the lung collapse persists, thoracotomy with organ revision is indicated chest cavity. The further scope of intervention depends on the nature of the lung damage. Superficial wounds located on the periphery of the lung can be sutured. In case of extensive destruction and crushing lung tissue resection is performed within healthy tissues ( wedge resection, segmentectomy, lobectomy, pneumonectomy). In case of bronchial rupture, both reconstructive and resection interventions are possible.

The prognosis is determined by the nature of the damage to the lung tissue, the timeliness of emergency care and the adequacy of subsequent therapy. In uncomplicated cases, the outcome is most often favorable. Factors that aggravate the prognosis are open lung injuries, combined trauma, massive blood loss, infectious complications.

Such damage is closed, and can be caused by impact, squeezing or shaking. In the most severe degrees of the disease, blood vessels and bronchi may be damaged. Hemorrhages appear very often.

There are times when lung contusion causes the formation of cavities filled with air or blood. In this case, the membrane itself covering the lungs is not damaged at all.

Lung contusion: symptoms

The very first sign that patients focus on is severe pain in the lung areas. At deep breath this pain intensifies many times over. Extremely unpleasant sensations can appear when bending over or in any other position of the body.

If bloody expectoration is noticed, then a lung contusion is possible. Symptoms that are not as common are tachycardia and bluish skin.

If the injuries were severe, the injured person may experience rapid breathing and shock. Very often the body lacks oxygen.

Bleeding, bruising, and swelling are often noticeable on the outside of the chest.

A lung contusion may not be immediately detected. Especially if the ribs are also damaged. Therefore, the patient may not even understand the extent of the damage.

Cases of pneumonia due to lung injury have been reported. It can be either focal or lobar.

Causes of injury

According to medical information, severe pulmonary contusion is a consequence closed injuries chest. This injury can be caused by falling from a very high altitude or hitting the steering wheel of a car during a traffic accident. Explosions and knife wounds cannot be ruled out. Usually, along with a contusion of the lungs, the heart, ribs and the chest itself also suffer.

Diagnostics

A lung contusion can be diagnosed in several ways:

1) During a superficial inspection. This procedure involves examining the chest. If hemorrhage is noticed on it, the lungs may be injured.

2) Using ultrasound. If there is a damaged area, an echo-positive shadow will appear on the screen.

3) Severe bruise lung can be determined while listening to the organ. This can be done by simply leaning your ear or using a stethoscope.

4) Using X-ray, you can determine the bruise due to polymorphic darkening of the lung in the injured area.

5) Examination of the lungs using a bronchoscope. It is a hollow tube with a light source at the end. Thus, swelling of the bronchi or accumulations of blood can be seen.

Urgent Care

If the victim is diagnosed with a lung contusion at first glance, treatment should be provided immediately. First urgent Care will help relieve pain, minimize consequences and alleviate symptoms.

To do this, please attach cold compress to the bruised place. You can use a frozen bottle or ice pack for this purpose. Apply this compress periodically for a few minutes.

There is no need to keep the compress on for too long. This can cause frostbite on the skin or colds.

Provide the victim with complete rest. It is advisable to place it in horizontal position and ensure that the patient moves as little as possible. For the first time after an injury, it is best to keep the injured person in a semi-sitting position. Before the doctor arrives, you should not use any medications. This can only make things worse.

Pneumothorax

During a chest injury, the patient may experience two serious conditions. These include pneumothorax and hemothorax.

A lung contusion (symptoms and treatment are determined during diagnosis) is a rather complex injury that requires urgent attention from a specialist.

Pneumothorax is the accumulation of air in the pleural area. This type of damage most often occurs when stabbed in the chest or during chest trauma. With a complex degree of the disease, a wound appears that a large number of air. In this case, the damaged part of the lung becomes inoperable. The most difficult case It is considered that Air enters, but cannot come back out. Thus, with each breath, the pressure in the cavity increases.

This condition can cause severe shock. Without urgent surgery, the victim may die.

If a person has an open wound in the chest, then first of all you need to seal it with improvised means. You can use a bag, oilcloth or film. Secure the sides with bandages, plaster or tape and wait for the ambulance to arrive.

Of course, such extreme measures are not strong, but they can save a person’s life before the doctors arrive. If possible, blood-absorbing materials should be placed in front of the airtight ones. Fabric is suitable for this.

Already in a hospital setting the following treatment is carried out:

The chest is made airtight again and the disease is transferred to a closed form.

An electric vacuum is used to suck out the air bubble from the pleura.

The pressure returns to normal due to drainage of the cavity.

Carrying out puncture of the cavity with air.

Hemothorax

This condition is characterized by hemorrhage in the pleural cavity. This phenomenon can cause a serious threat to human life.

If the size of the hematoma is too large, then the injured lung begins to compress the healthy one. That is, an injury to even one lung will disable both. A symptom of such injury is frequent but shallow breathing and sometimes loss of consciousness.

In extreme conditions with open wound the patient needs to put on a blood-absorbent bandage and seal the wound. If the wound is closed, a cold compress is ideal. It will narrow the blood vessels, and the amount of blood released will be much less.

In a hospital setting, the clotted blood in the cavity is drained and the lung is released.

Treatment of bruise

A lung contusion (symptoms and consequences are discussed by us) must be treated immediately. At home, this can be a cold compress.

If the injury is minor, then complete rest and painkillers will be enough. Pain and shortness of breath may be present for a few days before subsiding.

For bruises more strong character anti-inflammatory treatment is prescribed. Antibiotics are often used to prevent pneumonia.

A bronchoscopy procedure is prescribed to suck out excess fluid from lung cavity. A few days after the injury, physiotherapeutic procedures are prescribed to speed up the healing process.

Please note that in the next few days after injury, do not apply heat to the damaged area. It will only increase swelling and inflammation.

Preventing complications

To avoid complications and strengthen the respiratory system, experts have developed a set of special breathing exercises. Such exercises should be performed when the treatment of the disease is nearing completion. Good impact renders walking on fresh air. This is especially true for walks in a coniferous forest. Find an opportunity and go to such a place for a few days.

Consequences of a lung contusion

Whatever the degree of injury, it cannot be ignored, since the consequences of the disease can be extremely dangerous. The most common complication of a common lung contusion is this. This disease is very dangerous and quite often leads to death.

To prevent this from happening, urgently go to the hospital and get diagnosed. Timely medical assistance will be the key to a future happy life. Most often, with proper medical care, any complications can be avoided.

Lung contusion usually appears as a result of chest trauma. This closed damage, which can be caused by a blow, concussion, or compression of the lung. When a lung is contused, hemorrhages appear in the lung tissue, and it is also possible varying degrees damage to the bronchi and blood vessels.

Sometimes, as a result of such an injury, cavities may form in the lungs, filled with blood or air. In case of injury lung visceral pleura - the membrane that covers the lungs and chest, remains intact.

Symptoms

Symptoms of a lung contusion can vary, but most often it is pain in the place where the injury occurred. During deep breathing the pain usually gets worse. Also gain discomfort possible when changing body position, moving, bending. Coughing up blood and pulmonary bleeding are also signs of lung contusion, indicating damage to the lung tissue. With a lung contusion, tachycardia and cyanosis are possible, i.e. bluish skin color.

In the case of serious injuries, the injured person may experience severe respiratory failure, severe shock, and in some cases even shock lung syndrome, usually expressed in severe progressive shortness of breath, rapid breathing, and lack of oxygen in the body. Subcutaneous hemorrhages, as well as swelling and swelling may be visible on the chest at the site of injury.

Damage to the ribs and chest caused by the injury can make it difficult to recognize a lung contusion. Very often, a person cannot immediately understand that he has a lung contusion, since the first symptoms do not appear immediately, especially if the lung contusion was accompanied by only minor injuries.

Within a day or two, pneumonia may appear as a result of lung injury, which can be focal, with acute inflammatory process on a certain area of ​​the lung, or lobar, which is inflammation of the lung tissue due to infection.

Diagnostics

There are several ways to diagnose a lung contusion:

• During an external examination (most often, a bruise is determined by the presence of hemorrhage at the site of the chest injury)
• With the help of auscultation, i.e. listening to sounds when the organ is working. Auscultation is carried out both without special instruments (by applying the ear) and using a stethoscope or phonendoscope. Using this method, a doctor can detect a lung contusion by the presence of moist rales in the lungs - intermittent sounds similar to those that occur when air is passed through a liquid. Moist rales with a contusion of the lungs can be either fine-bubble, which are formed in the small bronchi and sound like air bubbles bursting instantly, or medium-bubble, similar to the bursting of medium bubbles, they are formed in the middle bronchi.
• With the help - on ultrasound, an echo-positive shadow appears when there is a lung contusion.
• Method - in this case, a lung contusion can be diagnosed by polymorphic darkening of the lung tissue in the area where the damage occurred. Also, an x-ray can show small and large hematomas, between which clearings will be visible in the image. Lung contusions can also cause pneumatoceles, which are filled with air, the presence of which will be shown by an x-ray.
• When examining the lungs using a bronchoscope, which is a hollow tube with a light source at the end. This procedure will show swelling of the bronchial mucosa, hyperemia (increased blood supply to the lung tissue) or blood accumulation in the lumens bronchial tree, if a person really has a lung bruise.

Diagnosis of a lung contusion must be carried out by a doctor, and in no case independently.

Treatment

Treatment of a lung contusion is carried out in order to prevent pulmonary hemorrhages, and to allow foci of hemorrhage to resolve, as well as to treat pneumonia, if it does appear. If the lung bruises are not severe and appear only in mild form, the patient is advised to rest for several days, and pain relievers and antibiotics are prescribed to prevent pneumonia. When minor injury complete cure usually happens quite quickly - within a few days.

To remove phlegm and blood from the lungs, it is prescribed sanitation bronchoscopy– removal of foreign contents and tumors from the trachea and bronchi by suction. If gas exchange in the lungs is disrupted due to injury, treatment is carried out by artificial ventilation. Severe damage does not disappear earlier than after a few weeks.

Physiotherapy is also used to treat a lung contusion.

Consequences

If the injury is not diagnosed in time and does not receive appropriate treatment, the consequences of a lung contusion can be very serious: the contusion can cause pneumonia of varying severity, which in turn can even lead to death. Punctures of the lung by a rib due to injury are also very dangerous - a person who does not receive help in a timely manner can lose a lot of blood.

In most cases, if the injured person consults a doctor in the first hours after receiving the injury, the lung contusion goes away without any unpleasant consequences.