Various unforeseen situations can happen in our lives. No one can be insured against an accident. Often, in case of accidents, falls from a height, domestic injuries, when practicing combat sports, defeat occurs chest.

This is a fairly broad group of injuries, which includes not only rib fractures, but also various injuries internal organs. Often such injuries lead to significant blood loss, respiratory failure, which, in turn, may lead to serious complications health and even death.

All chest injuries can be divided into open and closed

Closed chest injuries

home distinctive feature- absence of wound. Let's look at the types of injuries and their clinical picture.

1. Rib fractures:

• Chest pain that gets worse with breathing;
• Cyanosis of the skin and mucous membranes;
• Cardiopalmus;
• The chest is deformed;
• Localization of pain at the fracture site;
• Pathological mobility and bone crepitus.

1. Chest concussion:

• Tachycardia, arrhythmia;
• Cyanosis;
• Frequent, shallow breathing;
• Changes in the depth and rhythm of breathing.

1. Hemothorax:

Symptoms often vary depending on the degree. Most common symptom any hemothorax - an increase in body temperature after a chest injury. Hypoxia and shortness of breath may also increase.

1. Pneumothorax:

• A sharp deterioration in general condition;
• Increased heart rate, increased shortness of breath;
• Skin cold, cyanotic.

• Traumatic asphyxia.
• Increasing hoarseness of voice;
• Cyanosis of the upper half of the body;
• Swelling of the jugular veins;
• Increase in neck volume;
• Rapid development of cardiovascular failure.

1. Traumatic asphyxia.

• Sharp blueness of the skin, especially the nasolabial triangle;
• Numerous pinpoint hemorrhages of the upper half of the body;
• Cough with bloody sputum;
• Hearing, vision, hoarseness.

Since vital energy is concentrated in the chest important organs, damage to which can lead to serious consequences, emergency assistance to the victims must be provided immediately.

Providing first aid for closed chest injury

• Place the victim in a semi-sitting position;
• Prohibit talking and breathing deeply;
• Carefully free the victim from constricting clothing (unbutton, cut);
• If the victim is unconscious, tilt his head back, slightly to one side;
• If the victim is conscious, take a painkiller (analgin, baralgin, etc.);
• Until the doctor arrives, do not leave the victim, monitor consciousness and pulse.

Open chest injuries

All open chest injuries are divided into: penetrating and non-penetrating.

Non-penetrating – usually applied with some object (knife, stick). The victim's condition is satisfactory, the skin is dry, there is slight cyanosis of the lips, no air suction is observed during inhalation, there is no cough or hemoptysis.

Such injuries do not pose a threat to life unless vital organs are damaged.

First aid for non-penetrating chest wounds

• Calm the victim;
• Call an ambulance;
• Apply a pressure bandage from any available material to the wound;
• Before the ambulance arrives, monitor the condition of the victim.

Penetrating – significantly worsen the condition of the victim. Appears:

• Severe chest pain;
• Shortness of breath, feeling of lack of air;
• The skin is pale, with a cyanotic tint, especially in the area of ​​the nasolabial triangle;
• Sticky, cold sweat;
• The fall in blood pressure progresses, tachycardia increases;
• Both halves of the chest participate unevenly in the act of breathing;
• During inhalation, air is sucked into the wound;
• Foamy, bloody sputum and hemoptysis may appear.

Most often, penetrating chest injuries can be accompanied by injuries to such organs as:

• Lungs;
• Intercostal vessels;
• Heart;
• Diaphragm;
• Mediastinal vessels;
• Trachea, bronchi, esophagus;
• Organs abdominal cavity.

Emergency first aid for penetrating chest wounds

MUST BE PROVIDED IMMEDIATELY!

1. Call an ambulance immediately;
2. Do not leave the victim a single step, calm him down, sit him in a semi-sitting position;
3. Prohibit deep breathing, talking, eating, drinking;
4. For the first time, after identifying the patient, the wound should be covered with your hand;
5. Next, they begin to apply an occlusive dressing from scrap materials. Before applying the bandage, the victim is asked to make a deep exhalation.

• The area adjacent to the wound is treated with a solution of skin antiseptic (iodine, chlorhexidine, brilliant green);
• The skin around the wound is lubricated with Vaseline or any greasy cream (if available);
• The first layer is any piece of clean bandage, gauze or any fabric so that the edges of the bandage are 4-5 cm from the edge of the wound; secure along the edge with adhesive tape.
• The second layer is any oilcloth, a bag folded several times. It is also secured with adhesive tape.
• Several rounds of bandage are made around the body from above.

1. If there is a foreign object in the wound, under no circumstances should you try to pull it out. It needs to be fixed by covering the edge with napkins and securing with a bandage or adhesive plaster.
2. If the wound consists of 2 holes (entrance and exit), the bandage is applied to both wounds.
3. If help is provided to the victim after 40 - 50 minutes, then before the doctors arrive, the occlusive bandage is applied in the form of a U-shaped pocket, that is, it is attached only on 3 sides.

Any chest injuries are considered quite serious and dangerous injuries. Therefore, the correct, clear actions of the person who provides assistance to the victim will help preserve health and even life.

– 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 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. Based on the type of wounding weapon, they are divided into stab and firearm 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”. The hilar zone and root of the lung, including the bronchi of the first and second order and the great vessels, are dangerous for injuries - damage to this zone 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 rate is observed in acute and subacute periods, while long-term 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 usually associated with penetrating wounds of the chest with a knife, arrow, sharpening, military or hunting weapon, or 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. Affected areas lung tissue in this case, topographically correspond to the applied irradiation fields.

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 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. The consequence of blood loss is pale skin, cold sweat, tachycardia, and a drop in blood pressure. Signs of respiratory failure caused by a collapsed lung 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 respiratory and circulatory disorders.

In the late period, penetrating lung injuries are complicated by suppuration of the wound canal, bronchial fistulas, pleural empyema, pulmonary abscess, and 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 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, syndrome prolonged compression and other serious conditions. 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, expiratory shortness of breath of varying severity, and 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.

To correctly assess the nature of the damage, a chest x-ray in two projections is required. 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 other characteristic signs of various lung injuries. If the patient’s condition and technical capabilities allow, it is advisable 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, it is often necessary additional research: general radiography of the abdominal organs, 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 thoracic surgeon and a 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, it is necessary to hospitalize patients in a specialized department for 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 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 case of lung injuries accompanied by the occurrence of hemopneumothorax, 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, and infectious complications.

When the lungs are injured, first of all, it is necessary to insert some kind of tube into the wound, which is open on both sides. This could be a catheter, a pen, or another suitable item that is at hand. You just need to disinfect it first. This will help the excess air escape.

Orthopedist-traumatologist: Azalia Solntseva ✓ Article checked by doctor

Bullet wound

Such damage occurs due to fractured ribs and a simultaneous wound to the chest area. The situation is dangerous because it arises heavy bleeding and pneumothorax of valvular or open type.

These symptoms are very dangerous for maintaining the life of the victim.

They can cause complications that require urgent surgical intervention.

With a bullet wound to the lungs, when the victim has closed damage chest, it is necessary to urgently apply a pressure bandage. This should be done during maximum exhalation. These actions are performed when the ribs and sternum are broken.

If the victim has a significant pneumothorax closed type, then a puncture of the pleural cavity is performed. The procedure must be done when the mediastinum is displaced. Then be sure to perform aspiration of air from the cavity.

For subcutaneous emphysema, which is often a consequence of pneumothorax, there is no emergency treatment.

In case of a bullet wound to the lungs, you should very quickly cover the wounded area with a sealing bandage. A gauze napkin is placed on top of it. big size folded many times. After this, it should be sealed with something.

When transporting the victim to a medical facility, he should be placed in a semi-sitting position. If possible, he is injected locally with novocaine for pain relief even before he is taken to the doctor.

If the victim is in a state of shock, his breathing is impaired, then it will be very effective implementation vagosympathetic blockade according to Vishnevsky on the side that was injured.

Video

Penetrating trauma

Symptoms of penetrating - bleeding from a wound on the chest, characteristically the formation of bubbles - air passes through the wound.

If your lungs are injured, you must first do the following:

1. First, you should make sure that there is no foreign object in the wound.
2. Then you need to press your palm against the damaged area to limit the flow of air.
3. If the victim has a through wound, the exit and entrance holes to the wound should be closed.

1. Then you should cover the damaged area with material that allows air to pass through and secure it with a bandage or plaster.
2. The patient should be placed in a semi-sitting position.
3. It is necessary to apply something cold to the wound site, but first apply a pad.
4. If there is a foreign body due to a stab wound to the lung, then it is necessary to fix it with a roller made from improvised materials. You can secure it with cloth or tape.
5. It is strictly forbidden to independently remove stuck foreign bodies from the wound. After the procedures have been completed, the patient should be taken to the doctor.

Video

Closed wounds

A closed type of chest injury is characterized by a fracture of the chest bones. A closed heart injury is also typical, with no open wound in the chest cavity.

This injury is accompanied by traumatic pneumothorax, hemothorax or hemopneumothorax. With a closed chest injury, the victim develops traumatic subcutaneous emphysema and traumatic asphyxia.

A closed chest injury is an injury to the rib cage. In this case, the organs in the chest are injured, but the skin remains intact.

These injuries often occur as a result of one or more blunt force injuries or surfaces resulting from a traffic accident. They often injure the chest when they fall from a height, during a beating, a sharp one-time or numerous short-term, or prolonged compression a patient in a crowd of people or rubble.

Closed form

1. Promedol or analgin should be administered intramuscularly.
2. Inhalation anesthesia with nitrous oxide and oxygen.
3. Oxygen therapy for pain relief.
4. You can use a circular bandage made from a plaster or an immobilizing bandage. They should be used only when no deformation of the rib frame is visible.
5. When the condition worsens significantly, shortness of breath increases, and the mediastinum moves to the undamaged side, there is a need to perform a puncture of the pleural cavity. This will help convert a tense pneumothorax into an open one.
6. Any medications for the heart are effective. Antishock agents can be used.
7. After assistance has been provided, the patient should be taken to a medical facility.
8. The patient must be transported on his back or on a stretcher. The upper half of the body must be raised. The victim can be taken to the doctor in a half-sitting position.

What do we have to do

Lung injuries can be open or closed.

The latter occurs when the chest is sharply compressed.

It can also occur from a blow with a blunt object or a blast wave.

The open type of injury is accompanied by an open pneumothorax, but may also occur without it.

Injury to the lungs due to closed trauma is determined by the degree of damage. If they are seriously injured, bleeding occurs and the lung ruptures. Hemothorax and pneumothorax occur.

An open wound is characterized by a rupture of the lung. It is characterized by damage to the chest.

Depending on the characteristics of the damage, there are different degrees gravity. It's not easy to see the small closed minor injury breasts

When the lungs are damaged, the victim experiences hemoptysis, subcutaneous emphysema, pneumothorax and hemothorax. It is impossible to see accumulated blood in the pleural cavity if there is no more than 200 ml there.

The techniques that can be used to help the victim are varied. Their choice is determined by the severity of the damage.

The main goal is to quickly stop the bleeding and restore normal breathing and cardiac activity. At the same time as treating the lungs, the chest walls should also be treated.

Causes

Closed injuries are the result of an impact on a hard surface, compression, 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 from a knife, arrow, sharpening, military or hunting weapon, or shell fragments.

In addition to traumatic injuries, damage may occur due to physical factors, such as ionizing radiation. Radiation damage to the lungs usually occurs in patients receiving radiation therapy for cancer of the esophagus, lungs, or breast. The areas of lung tissue damage in this case topographically correspond to the irradiation fields used.

The cause of damage can be diseases accompanied by rupture of weakened lung tissue during 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 are caused by oxygen toxicity, volutrauma, barotrauma, atelectotrauma, and biotrauma.

Diagnostics

External signs of injury: the presence of hematomas, wounds in the chest area, external bleeding, air suction through the wound channel, etc.

Physical findings vary depending on the type of injury, but most often there is decreased breathing on the side of the affected lung.

To correctly assess the nature of the damage, chest radiography in two projections is required.

X-ray examination reveals 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 other characteristic signs of various injuries lungs.

If the patient’s condition and technical capabilities allow, it is advisable 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), a therapeutic and diagnostic pleural puncture can be performed.

In case of combined injuries, additional studies are often required: general radiography of the abdominal organs, 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 used. At the diagnostic stage, a patient with lung damage should be examined by a thoracic surgeon and traumatologist.

First aid for lung injuries

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Superficial lung wounds may have little effect on the general condition of the victim. Deep wounds, especially in the hilar zone, can be extremely life-threatening due to bleeding into the pleural cavity or into the lumen of the bronchus, as well as tension pneumothorax.

An unconditional sign of lung injury is the presence of hemopneumothorax or pneumothorax; hemoptysis may be observed, and due to damage to the intercostal vessels - hemothorax.

The diagnosis is established based on the presence of a wound to the chest wall, signs of pneumothorax ("box" percussion sound, absence or sharp weakening of breath sounds on auscultation), hemoptysis.

Urgent Care. Applying a bandage to the chest wound, oxygen, cardiac medications. Puncture of the pleural cavity.

Hospitalization in the thoracic department.

HEART WOUND

It is considered to be an extremely dangerous injury. Extensive injuries lead to immediate death. About 15% of victims with stab and small incised wounds of the heart can live for some time even without help. They die, as a rule, not from acute blood loss, but from developing cardiac tamponade. The location of the wound matters.

Developing cardiac tamponade is characterized by severe general state patient, low systolic and high diastolic blood pressure, tachycardia with a very soft, barely perceptible pulse, swelling of the veins of the neck, upper limbs, face, cyanosis of the skin and mucous membranes.

It must be remembered that any wound located in the projection of the heart and large vessels is dangerous in relation to possible injuries to the heart. Noteworthy is the discrepancy between the severity of the victim’s condition and the size of the wound, and the condition may worsen before our eyes.

The diagnosis is made based on the location of the wound, signs of cardiac tamponade, and the general serious condition of the patient. Mistakes are possible when the wound is inflicted with a long knife or an awl, and the wound is located outside the projection of the heart, especially in the back, and is accompanied by an open pneumothorax. With multiple wounds of the torso and limbs, the wound in the projection of the heart can be viewed.

Emergency care and hospitalization. At the slightest suspicion of a heart injury, immediate delivery of the victim to the hospital for emergency thoracotomy and suturing of the heart wound is necessary. During transport to the hospital, all surgical services must be notified and everything prepared for emergency surgery. The victim is taken directly to the operating room, bypassing the emergency department. Therapeutic measures along the route are reduced to maintaining life functions: oxygen, artificial ventilation lungs, transfusion of blood substitutes, cardiac drugs. If it is not possible to quickly transport the patient to a surgical hospital, a Larrey puncture of the pericardium is performed, leaving a thin polyethylene catheter in the pericardial cavity. The end of the catheter is clamped with a clamp and attached with a plaster to the chest wall. Every 15-20 minutes (or more often) blood is sucked out from the pericardial cavity. In some cases, a thin catheter can be inserted through the wound into the heart area and remove at least some of the blood from the pericardial cavity.

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 and with open pneumothorax. In addition, there are bullet and shrapnel wounds, which can be blind and through.

Pathological data

Penetrating stab wounds breasts are characterized by smooth walls of the wound channel and usually minor 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 to the root of the lung, where large vessels and bronchi pass, are 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 a narrow wound channel in the lung is filled with 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. Their skin is pale, their face and lips are bluish. The pulse is frequent, weak filling. Blood pressure is reduced. Severe shortness of breath is noticeable. 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 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 function lung 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 an extensive receptor zone, irritation of which in open pneumothorax leads reflexively to breathing disorders and cardiac activity.

Open gives a sharp decrease in the depth of breathing - 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 disturbances in 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 result in death in a very short time. 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 breathing movements in a 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 penetrating gunshot wounds, the direction of the wound channel is important, and when examining blind wounds, the presence of foreign bodies is important. 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 shown clinical experience, 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 blood, 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. At 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 the air from the pleural cavity, if possible, achieving straightening of the lung.

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 require 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, turning a closed pneumothorax into an open one, giving 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. First aid is important - immediately covering the wound with a bandage that prevents the free flow of air. In order first medical care The patient is injected with morphine under the skin and a vagosympathetic blockade is performed.
IN medical institution if the wounded person has severe, life-threatening bleeding, begin immediately, carrying out anti-shock measures, including (required) blood transfusion.

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. Incised 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 posterior sections 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 wounds of the chest with a closed pneumothorax, as well as after surgical treatment and suturing of wounds, the 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 determined by 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