Signs of lung injury. Treatment of penetrating chest wounds. Ventilator-induced lung injury

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Anything can happen in life.
Be ready for anything!

It’s not possible to look at everything possible situations and in order to provide high-quality assistance in case of a knife wound, you must have medical education and practice, but it is still worth trying to provide first aid, which can prolong a person’s life, before the ambulance arrives, having at least minimal knowledge.

Knife wound to the lung area

Knife wound to the chest

If you hear a suction sound when you breathe during a knife wound, the first step is to close the wound - without even waiting for help to arrive.

If possible, the wounded person should inhale and exhale. After exhaling completely, press down on his chest. Then try to quickly cover the wound with a plastic bag, oilcloth, or something similar to prevent air from entering the wound. Stick a bandage on top. Apply a cooling pack or something cold, this will at least help relieve the pain and slow down the bleeding. If the wounded person feels worse after this or has difficulty breathing, remove the bandage, allow the air to escape from the chest cavity and close the wound again.

Monitor whether the victim’s airways are clear, whether there is a pulse and breathing. If the person is conscious, they need to be seated or the head and shoulders elevated. This will prevent blood from filling the intact part of the chest cavity, and healthy lung will be able to continue working.

What to do if the knife is in the wound?
If the knife is in the wound, do not remove it. If you take out the knife, blood will begin to flow out heavily, and the person may not survive until help arrives. Secure the knife with a thick bandage or tape to prevent it from moving and seek immediate medical attention.

What to do if any organ protrudes from the wound?

If any organ is protruding from the wound, cover it with a sterile bandage or clean cloth. To prevent it from drying out, water the bandage with clean drinking water before the ambulance arrives.
Do not touch it or try to put the organ back in.

How do doctors deal with a stab wound?

Doctors check to see if breathing is normal. It may be necessary to insert a tube into the chest to expand the lung, allowing proper pressure in the chest and allowing blood to flow out if there is a hemothorax. In some cases, oxygen and a mechanical ventilator are needed to maintain breathing.
Then the bleeding is stopped. It's possible surgical intervention. If there is slight bleeding, the wound is bandaged sterile bandages. Painkillers, antibiotics and a tetanus shot may be prescribed to avoid infection.

Everything that doesn't kill us makes us stronger. Be ready for anything!

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 intensifies. 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 cases of serious injury, the injured person may experience respiratory failure. strong degree, 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, as a result of a lung injury, pneumonia may appear, which can be focal, with an acute inflammatory process at a certain lung area, 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 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. IN mild case injury, complete healing usually occurs 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. Also very dangerous lung punctures rib due to injury - a person who does not receive help in a timely manner may 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.

– lung injuries accompanied by anatomical or functional disorders. Lung injuries vary in etiology, severity, clinical manifestations and consequences. Typical signs lung injuries serve sharp pain in the chest, 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 defect chest wall) and open (with the presence of a wound opening). Group closed damage lungs 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, their damage is possible 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 involve rupture of weakened lung tissue due to coughing or physical exertion. 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 phenomena occur, respiratory distress syndrome. 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. The “companions” of a lung rupture are pneumothorax, hemothorax, cough with bloody sputum, and subcutaneous emphysema. A bronchial rupture may be indicated by the patient's shock, subcutaneous and mediastinal emphysema, hemoptysis, tension pneumothorax, or 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 respiratory failure symptoms caused by lung collapse include difficulty breathing, cyanosis, and pleuropulmonary shock. With an open pneumothorax, air enters and exits during breathing. 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 high-pressure mechanical ventilation. This condition may be accompanied by the development of subcutaneous emphysema, pneumothorax, lung collapse, mediastinal emphysema, air embolism and threats 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, prolonged compression and other serious conditions. Blowout specified substances damages not only 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 reveals mediastinal displacement and lung collapse (with hemo- and pneumothorax), spotty focal shadows and atelectasis (with lung bruises), 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 a bronchial rupture, detecting a source of bleeding, a 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, carried out antishock therapy, replenishment of blood loss (transfusion of blood substitutes, blood transfusion).

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

In the case of lung injuries accompanied by the occurrence of hemopneumothorax, the first priority is aspiration of air/blood and expansion of the lung through therapeutic thoracentesis or drainage of the pleural cavity. If the bronchi and large vessels are damaged and the lung collapse persists, a thoracotomy with revision of the thoracic cavity organs is indicated. 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. If extensive destruction and crushing of lung tissue is detected, resection is performed within healthy tissue ( 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 treatment 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.

Penetrating chest wounds are inflicted with bladed weapons and firearms. There are also industrial and household open damage.

Penetrating chest wounds are divided into wounds without open pneumothorax, with open pneumothorax. In addition, there are bullet and shrapnel wounds, which can be blind and through.

Pathological data

Penetrating stab wounds of the chest are characterized by smooth walls of the wound channel and usually small bone damage. With these injuries, large blood vessels are often damaged. The severity and subsequent course of the injury depends on the damage to the lung. Injuries lung root where they take place large vessels, bronchi, usually fatal; such wounded people soon die from severe intrapleural bleeding. Injuries to the middle layer of the lung are also dangerous due to large blood losses. Only when the surface layer of the lung is damaged, bleeding can be moderate and stop relatively quickly on its own.

With gunshot wounds, the skin damage is often small. But the destruction of deep tissues (subcutaneous tissue, muscles, fascia, bones) is more significant.

Fragments of damaged ribs or scapula are carried away by the wounding projectile and themselves become instruments of destruction, tearing intercostal vessels and the lung. Damage to the lung can be different: sometimes the narrow wound channel in the lung is filled blood clots, sometimes extensive ruptures and crushing of the lung occur with the presence of large pieces of tissue doomed to necrosis.

With penetrating wounds (usually gunshot wounds), pleural empyema (total and limited) often develops. In a relatively long period after injury, the formation of broncho-pleural or broncho-cutaneous fistulas is possible.

Penetrating chest wounds without open pneumothorax

The presence of a closed pneumothorax is often found with penetrating wounds. When the wound edges are glued, the flow of air stops and a closed pneumothorax occurs.

Symptoms of wounds without open pneumothorax vary greatly depending on the severity of the injury, the presence of shock, and the severity of intrapleural bleeding. Sometimes the victim feels so good that he does not even agree to go to bed. In other cases, on the contrary, he soon falls into a serious condition.

With small hemothorax and small accumulations of air, the patient’s condition usually remains satisfactory. In the first days there is a cough and a moderate increase in temperature.

Wounded patients with significant lung destruction and large hemothorax are often in serious condition. They complain of pain, dizziness, severe shortness of breath and cough. Skin they are pale, their face and lips are bluish. The pulse is frequent, weak filling. Blood pressure downgraded. Conspicuous severe shortness of breath. With a change in body position and the slightest physical effort, shortness of breath increases even more and the patient suffers seriously from pain and a feeling of suffocation.

With hemorrhage into the pleural cavity, it is noted, which is especially pronounced with significant intrapleural bleeding. Physical examination reveals dullness consistent with fluid accumulation. Breathing is not audible here. Voice tremors are absent or weakened. The heart is displaced, and this displacement is more significant the more it is.

The displaced lung is compressed and lacks air, so only weakened breathing with a bronchial tint can be heard above the fluid level.

The spilled blood is an irritant to the pleura, so already in the first days of injury there is a combination of hemothorax and pleurisy (hemopleuritis). In the absence of infection, the spilled blood is gradually absorbed, which has a beneficial effect on the general condition of the wounded.

When hemothorax resolves, extensive adhesions and moorings sometimes form. As a result, the mobility of the ribs and diaphragm decreases, which reduces respiratory lung function. Often adhesions fix the pericardium and mediastinal pleura, sometimes complicating the activity of the heart.

Penetrating chest wounds with open pneumothorax

With an open pneumothorax, a free communication of the pleural cavity with the atmosphere is established. The pleura and lung are a large receptor zone, irritation of which in open pneumothorax leads reflexively to respiratory and cardiac disturbances.

Open gives sharp decrease breathing depth - up to 200 cm3 instead of 550-600 cm3, which depends on the collapse of the lung, displacement of the mediastinal organs, which is not only pushed to the healthy side, but also moves during breathing (balloting, or floating, of the mediastinum). With open pneumothorax, paradoxical breathing occurs.

Open pneumothorax causes significant distress external respiration, changes hemodynamics, leads to hypoxemia and serves as a source of reflex irritation of brain centers important for life.

Penetrating chest injuries with open pneumothorax are the most severe injuries to the chest.

Many injuries end in very short term death. Those wounded who manage to be taken to hospitals are often in traumatic shock.

With penetrating gunshot wounds, in 90% of cases the lung is damaged and only in 10% the wounding projectile passes through the reserve space of the pleura, bypassing the lung tissue. In addition, 79% of the wounded have damage to the ribs, less often there are injuries to the sternum, scapula, and collarbone.

Most of the wounded with open pneumothorax, even in the absence of severe lung damage, die if they do not receive surgical care.

Such wounded people are restless and suffer from severe pain, painful cough and shortness of breath. The victim finds no relief from the feeling of tightness in the chest and severe suffocation, which intensify with the slightest physical exertion.

When examining such a wounded person, one notices pallor, cold sweat, and cyanosis. Breathing is rapid and sometimes reaches 40 respiratory movements per minute. In most cases, the pulse is weak. Blood pressure is reduced.

Air passes through the wound into the chest cavity. When you cough, blood and bubbles are sometimes expelled from the wound. With defects of the chest wall, it is possible to see the parietal pleura or the edge of the lung. However, with narrow wounds of the chest, the presence of an open pneumothorax is often difficult to detect during external examination.

The clinical course of penetrating chest wounds with pneumothorax is severe. If surgical treatment of the wound is refused or even untimely, or its closure with sutures is delayed, it inevitably develops. purulent pleurisy, darkening the forecast.

Diagnosis of wounds

When diagnosing penetrating chest wounds, it is necessary to find out the nature of the wound - whether it is penetrating or non-penetrating. The presence of pneumothorax or hemothorax undoubtedly indicates the penetrating nature of the injury.

When assessing the nature of through gunshot wounds, the direction of the wound channel is important, and when examining blind wounds, the presence foreign bodies. Of course, this criterion alone is not enough to resolve the issue regarding the degree of damage to the lung, but in combination with other signs it gives an approximate idea of the possible destruction along the path of the wounding projectile.

X-ray examination plays an important role in the diagnosis of lung injuries. The extent of bone destruction is most accurately revealed by radiography. Pneumothorax and hemothorax are also accurately determined radiographically. Lung hemorrhages and foreign bodies can be detected mainly by radiography. Finally, fluoroscopy and radiography make it possible to accurately and objectively note the dynamics of changes in the lung and pleural cavity (disappearance of pneumothorax, resolution of hemorrhages in the lung, decrease or increase in fluid).

Pleural puncture can detect changes in the transparency and color of the pleural fluid, as well as obtain material for bacteriological culture.

When examining pleural punctures, it is established that in cases uncomplicated by infection, the shed blood is first based on hemoglobin content and leukocyte formula approaches the blood circulating in the bloodstream. Then the percentage of hemoglobin decreases and by the 10th day after injury reaches 15-20 or even less. With uninfected hemothorax, the leukocyte count in some cases shows an increase in leukocytes, and in others - eosinophils. Infection of hemothorax is manifested by hemolysis, an increase in the percentage of neutrophils in the leukocyte formula.

Resolving the issue of the penetrating nature of the wound is sometimes very difficult. We are talking about wounded people who initially do not experience pneumothorax or hemothorax. As clinical experience shows, in these cases, even with primary surgical treatment, it is not possible to find a defect in the pleura and the wound is considered non-penetrating. However, in the coming days, when repeated x-ray examination it is possible to determine a small amount of air and prove the penetrating nature of the wound where it was denied even when the wound canal was opened and its edges were excised.

Treatment of penetrating chest wounds

Until recently, conservative trends prevailed in the treatment of penetrating wounds.

Currently, the urgent goals of treating penetrating chest wounds are to stop fatal bleeding, restore normal breathing, cardiac activity. At the same time as solving these urgent problems, it is necessary to take measures to prevent wound infection.

Choice therapeutic methods dictated by the characteristics of the injury. With modern surgical capabilities, the following principles for the treatment of penetrating wounds can be outlined.

In case of knife or gunshot wounds of large vessels of the chest wall (a. intercostalis, a. mammaria int. a. subclavia), where there is rapidly increasing intrapleural bleeding and a mortal threat to the victim, immediate surgical treatment is required. In providing assistance to these wounded, mistakes are often made, since, following the tactics of conservative treatment of hemothorax, they are content with suctioning the blood and prescribing hemostatic agents. However, such treatment, which is quite appropriate for hemothorax caused by damage to the peripheral parts of the lung, turns out to be untenable for intrapleural bleeding due to injury to the mentioned arteries of the chest wall. The experience of peacetime surgery shows that in case of damage to the intercostal arteries, the mortal threat of intrapleural bleeding should not be stopped even before a wide thoracotomy in order to ligate the damaged vessels, which bleed especially heavily if they are ruptured in the posterior sections near their origin from the aorta.

If the intrathoracic artery is injured, sufficient surgical access should be provided. For this purpose, it is necessary to resect the costal cartilages closest to the wound site and, if necessary, bite the edge of the sternum with Luer forceps. With this approach it is difficult to avoid opening the pleura. If the pleural cavity is accidentally or intentionally opened, you should insert a finger into it and press the artery from the inside to the sternum or costal cartilage, after which all further manipulations to expand surgical access proceed calmly. Further, opening the pleural cavity allows for an inspection of the organs (lungs, pericardium), which is extremely important for deciding the volume of surgical assistance.

In case of injury subclavian artery or veins with damage to the adjacent pleura and intrapleural bleeding, there is a need for resection of the clavicle and dissection of the tissues of the subclavian space to provide the necessary access to the bleeding large vessels.

Intrapleural use is mandatory for any wound, especially gunshot wounds.

If the root of the lung is injured with damage to the large blood vessels emergency surgical treatment is indicated. With conservative treatment, such wounded people die from intrapleural bleeding.

Surgical assistance consists of a wide opening of the pleural cavity and ligation of damaged vessels. Since the patient’s condition in such cases is usually serious, in order to provide emergency assistance it can be difficult to decide on more radical treatment than ligation of bleeding vessels. Of course, if the wounded person’s condition allows, then the non-viable part of the lung should be removed.

After stopping the bleeding, you need to suture the wound, suck out air from the pleural cavity, if possible, achieving lung expansion.

It is left underwater for 1-2 days for the outflow of blood and pleural exudate, as well as for the introduction of antibiotics into the pleural cavity.

If, with a penetrating wound of the chest without an open pneumothorax, there is no rapidly increasing intrapleural bleeding, then the issue of treatment is resolved differently.

Even with gunshot wounds, which have the most unfavorable course, patients with a penetrating chest wound without an open pneumothorax often do not need surgical treatment. We are talking about victims who had minor wounds and minimal bone damage. Indeed, with small wounds of the chest, there is no point in cutting the tissue and turning a closed pneumothorax into an open one, which gives a more severe clinical course. In case of severe destruction of the tissues of the chest wall, on the contrary, careful treatment of the wound with resection of crushed ribs is necessary. In this case, it is possible to open the pleural cavity.

In some wounded patients, revision of the pleural cavity may be necessary. Indications for revision are severe intrapleural bleeding, suspicion of significant destruction of the lung and the known presence of foreign bodies.

Treatment of penetrating chest wounds with open pneumothorax is difficult. Important has first aid - immediate closure of the wound with a bandage that prevents the free flow of air. As first aid, the patient is injected with morphine under the skin and a vagosympathetic blockade is performed.
In a medical institution, if a wounded person has severe, life-threatening bleeding, they begin immediately, carrying out anti-shock measures, including (mandatorily) blood transfusions.

The most important goal of surgery for wounds with open pneumothorax is to close the wound and eliminate the gap in the pleural cavity. To achieve this, the wound is excised, removing non-viable soft fabrics and removing bone fragments that have lost contact with the periosteum (ribs, shoulder blades). Often it is necessary to resort to resection of broken ribs.

When the chest wall wound is treated, you need to examine the pleural cavity and remove any foreign bodies that have entered. Cut lung wounds should be closed with single catgut sutures. If part of the lung is crushed from a gunshot wound, removal of the destroyed tissue (marginal resection of the lung, lobectomy) is indicated, of course, if the general condition of the wounded person allows it.

In many cases of knife and gunshot wounds, there is only minor damage to the lung tissue, and the bleeding has already stopped by the time of the operation, so there are no indications for intervention on the lung. In such wounded people, the wound must be sutured tightly after careful surgical treatment.

For large defects of the ribs and intercostal muscles, rapprochement of the wound edges after PSO is not possible, so it is advisable to cut out a flap from nearby muscles and sew it into the defect.

Surgical treatment of transscapular wounds requires special attention. Fracture of the scapula and ribs, as well as damage to the muscles located here, make it necessary to provide sufficient access to the posterior parts of the pleura. For this purpose, damaged and non-viable muscles have to be excised, and the broken part of the scapula removed, exposing the destroyed ribs covered by it. Covering the defect of the chest wall after resection of the ribs is carried out by displacing and fixing adjacent muscles or by cutting out and moving a muscle flap.

In case of penetrating chest wounds with closed pneumothorax, as well as after surgical treatment and suturing of wounds, transformation of an open pneumothorax into a closed one, it is necessary to pay the most serious attention to the earliest and possibly most complete removal blood and exudate from the pleural cavity, achieving expansion of the lung and contact of the pleural layers.

Strict is required clinical observation patient care and x-ray monitoring. The accumulation of exudate usually indicates the beginning infectious process in the pleura. In the presence of cloudy pleural exudate, and even more so with positive bacteriological cultures intrapleural administration of antibiotics is required. When microbes are detected in pleural exudate, it is advisable to choose the most active drug, which is easily installed using the microbiological disk method. The use of antibiotics according to a pattern, without proper bacteriological control, leads to the introduction of a drug that is ineffective for a given microorganism (or association of microbes), and sometimes causes the formation of forms of microbes resistant to it.

The article was prepared and edited by: surgeon

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. Pass here segmental bronchi and vessels.

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

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 of 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. With massive destruction lung tissue A lobectomy is performed within one lobe. 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 thoracic of the 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.