A stab-cut wound is distinguished by its depth, always exceeding the length, often has a slit-like shape, sharp (or one sharp) ends and even edges arising from the movement of the blade when removing the knife at an angle. In this regard, wounds can also have a carbohydrate form. Isolation of the main and additional incisions is significant not only for the diagnosis of the piercing-cutting action, but also allows one to judge the width of the blade of the traumatic tool. To distinguish the main incision from the additional one, one must take into account that the latter departs at an angle, often at a certain distance from it, and is better detected with stereomicroscopy.
First of all, the type of blade is determined, and if there is a butt (back), its features.
With the action of a one-sided tool, that is, a tool with a butt, the end of the wound on this side can be rounded, "p" or "M> -shaped, sometimes with tears along the edges. From the side of the blade action, the end of the wound is sharp with a protruding notch formed from the cutting action.
The peculiarity of the end of the wound from the side of the butt of the knife depends on its thickness, for a butt thinner than 2 mm may not affect the skin and leave an acute angle also from the severity of the butt ribs, the degree of pressure on it when the knife is immersed. In the latter case, this end may be besieged. Sometimes the establishment of even one sign of a knife, for example, the presence of a back, can exclude the original version and direct the investigation along a different path. The proof of the possibility of using the revealed knife will allow solving the crime.
One of the important features of a piercing-cutting tool is the length of its blade. It is judged by the depth of the wound channel, which is not always technically easy. It should be borne in mind that the length of the canal in the abdominal cavity, in the pliable soft tissues due to their deviation during immersion, may be greater than the length of the blade of the "tool itself. Also, we must not forget that it is necessary to add the thickness of the clothing to the length of the canal, according to the localization of the wound. In this case, it is usually reflected only the length of the embedded part of the blade, except for cases where damage from the limiter is detected along the edges of the wound.
Finally, it should be borne in mind that at the time of injury, the victim could be in a bent position, and when examining a straightened body, the wound channel may be located along one line. When the knife is introduced to the limiter, which is determined by the sedimentation from the pressure on the skin, it is established that the wound channel reflects the entire length of the blade.
For penetrating and non-penetrating wounds, depending on the part of the body, various research techniques are used to establish the length of the blade.
The morphological features of the damage allow one to judge some of the details of the structure of the tool. With the full immersion of the blade, as noted above, the abrasion near the edges of the wound can repeat the shape of the contact of the limiter, and in the presence of the barb that is on the penknives, additional damage is revealed on the side of the sharp end near it.
The features of the tool include the detection of rust and other contamination of the blade.
These features are better visible with stereomicroscopic examination, sometimes they can only be detected when using this method, or determining metallization using chemical color reactions to iron. Most often, this is the Perls test, when using it, a 2% solution of yellow blood salt and 2% hydrochloric acid are poured onto the damaged area, then everything is washed off with distilled water. The formation of a blue-greenish color indicates the presence of iron compounds. You can use the Tierman reaction, as well as contact-diffusion methods for obtaining a print on photographic paper.
2. Forensic medical examination for forced sexual intercourse. Inspection
the scene of the incident. The main features, the method of conducting forensic
medical examination of the victim. Laboratory research methods.
Incrimination under articles of the Criminal Code of the Russian Federation.
Rape, according to Article 131 of the Criminal Code of the Russian Federation, is sexual intercourse with the use of violence or the threat of its use, as well as the use of the helpless state of the victim. The Criminal Code provides for aggravating circumstances of rape, including the commission of a group of persons; committed with particular cruelty to the victim or resulting in death, serious harm to health or infection with a venereal disease, as well as committed with a 14-year-old or minor.
A healthy woman can only be raped when she is injured, threatened, or helpless. Expertise on sexual crimes in connection with severe mental trauma, as well as due to an intimate nature, has its own characteristics.
After getting acquainted with the decision on the appointment of the examination and with the document proving the identity of the woman, her questioning follows.
Particular importance is attached to semilunar abrasions, oval bruises located on the inner surfaces of the thighs. Given that they are formed from pinching with the fingers when the thighs are extended to the sides, they can be considered a characteristic injury for rape. Abrasions and bruises, bite marks on the mammary glands and genitals are of a sexual nature. The external genital organs, the condition of the hymen and damage to it, traces of blood or semen on the body, hair pieces, textile fibers are examined in detail. Much importance is attached to the study of the clothes that the victim was wearing at the time of the violence. It may have traces of semen, blood, and damage characteristic of the struggle.
Along with these secretions, a smear is taken from the vagina and cervix on a gauze swab, which is transferred onto 6 slides, and after drying by the investigator, by a special resolution, it is sent for a forensic biological examination. Control material is presented at the same time. It should be noted the importance of the fastest removal of the smear, which is done by the expert on duty at the scene. By the way, the inspection of the scene, also carried out with a medical expert, allows you to fix the general situation and traces of the struggle, to remove the torn buttons, buckles, parts of women's underwear, blood, hair, semen.
It should be borne in mind that sexual intercourse, in addition to sperm, is indicated by sexually transmitted infection with a venereal disease, the presence of pregnancy that coincides in time with rape. Therefore, such an examination is carried out with the participation of a venereologist, obstetrician-gynecologist.
An expert assessment of the results obtained should be careful, firstly, because the simulation of rape is not excluded. Secondly, voluntary sexual intercourse often does not differ from rape in terms of objective signs of the examination of the victim. In this case, there may be some damage, and on the contrary, during forced sexual intercourse, they may not be. Therefore, it is important to emphasize the possibility or exclusion of damage under certain circumstances. As already noted, the investigator draws a conclusion about rape on the basis of an expert opinion and other evidence.
3. Poisoning with vinegar essence, clinical picture. Sectional and
laboratory diagnostics.
Acetic acid more common in everyday life in the form of vinegar essence. It contains 50-80% acetic acid. Table vinegar contains 6% acetic acid. A lethal dose is 15 ml of vinegar essence or a glass of table vinegar.
After taking acid, strong vomiting of brown masses appears, emitting a characteristic vinegar smell. There are severe pains along the digestive tract, swelling of the mucous membrane of the upper respiratory tract, sometimes a sharp cough in case of poisoning with concentrated acid. Death comes quickly. When experiencing, a poisoned person develops jaundice due to hemolysis of erythrocytes, diarrhea with brown masses mixed with scarlet blood joins, the temperature rises, blood is found in the urine, and bloody discharge from the vagina may also appear in women. Death can occur in the first hours from shock, during experience - from various complications, and sometimes long after poisoning. The outcome may be the same as in case of poisoning with inorganic acids.
On external examination, this is a chillic burn of the oral mucosa. Internal examination is characterized by dehydration and thickening of the tissue. The scab is brownish in color. Damage to the mucous membrane of the esophagus, stomach, which is perforated in places of prolonged contact, and acid pours out into the abdominal cavity, damaging organs.
TICKET number 22
1. Sudden death from ischemic heart disease. Causes of death. Sectional diagnostics.
Laboratory research methods.
Sudden death occurs in the midst of seeming complete health and unexpectedly for others.
At the heart of ischemic heart disease of this widespread disease are acute and chronic pathological conditions caused by organic lesions of the coronary arteries of the heart (thrombosis, atherosclerosis), or the functional state is the spasm of these arteries, which impedes the nutrition of the heart muscle and leads to myocardial infarction or focal dystrophy, angina pectoris, disorders, heart rate, acute coronary insufficiency.
The conclusion about the cause of death must include established facts that contribute to the onset of sudden death. Such risk factors, suddenly leading to death, are: unfavorable meteorological conditions (abrupt change in atmospheric pressure, air temperature), physical overstrain (even insignificant) in patients with coronary artery disease; psycho-emotional impact, especially if it was unexpected.
Spasm, thrombosis, embolism, stenosis. Morphological signs appear 40-60 minutes after the start. Electrical instability is noted. Polarizing microscopy + staining of the myocardium with secretin orange or Reis is performed. In biochemical blood analysis - ALT, ACT, the disappearance of glycogen from the ischemic area, CPK, LDH, K + increase. Macroscopic manifestations in a day. Formation of a white corolla - 3rd day, then -> red.
2. The forensic significance of the bruise. Determining the age of it
origin. Possibilities of identifying an object depending on its shape.
Ways to distinguish it from a cadaveric spot.
A bruise is a subcutaneous hemorrhage that can be superficial or deep (hematoma) and manifest as a discoloration of the skin.
Despite the fact that they do not cause health disorders, bruising is of great forensic importance, since they show that violence was made in the form of a mechanical action with a blunt object, indicate the place of application of force. Sometimes, according to these skin lesions, a targeted study reveals damage to the underlying tissues, internal organs, fractures. Localization of bruises, taking into account other features, makes it possible to judge the nature of the violence. So, oval bruises on the neck suggest that it is being compressed, which happens when strangling with hands. The same injuries on the inner surface of a woman's thighs are characteristic of their spreading apart during forced sexual intercourse. Multiple bruises on the dorsum of the hands and wrist joint indicate self-defense. The shape of the bruises often repeats the shape of the impact surface of the injured object or that part of it that was in greater contact. For these damages, the question of the approximate prescription of their application is being resolved.
At limited the impact of the impacting surface is less than the damaged body surface. When struck by such objects (for example, with a hammer), bruises are formed, often with sedimentation along the edges.
The shape and size of the damage depends on the features of the angular edge. At ularah prelims with longitudinal bruising or wounds are formed with a two-sided, rectilinear edge (board, etc.). Objects with a two-sided, arcuate edge, like at the bottom of a bottle, will give bruises or wounds of an arched shape.
The severity of bruising in the circumference of the wound depends on the angle between the planes of the object, and the smaller the angle, the weaker the hemorrhage along the edges of the wound. As the angle of the injuring object sharpens, the edges of the wound become smoother.
On blows preliminaries with multifaceted(pyramidal ^ corners characteristic wounds of a star-shaped form are formed, and the number of wound rays often corresponds to the number of edges (ribs) converging at an angle. So, an object with a triangular angle (for example, the corner of a brick, a board) gives a three-ray abrasion or wound, each ray of which is formed by the edge of the corner of the object. These rays, abrasions or wounds can be of different lengths depending on the direction of the impact.
Triangular, multifaceted and conical obtuse angles according to the mechanism of action, they are transitional to piercing tools. Moreover, the sharper the angle, the weaker the bruising and sedimentation along the edges of the wound formed. With a significant impact force and sufficient gravity, a tool with a multifaceted angle gives characteristic depressed or perforated fractures of flat bones.
When examining a corpse, it is sometimes possible not to notice bruises located in the area of cadaveric spots or on the border with them. In such cases, cruciform incisions are made in suspicious areas: in the presence of bruising, limited hemorrhage is visible. The higher parts of the body do not have cadaveric spots.
3. Forensic and forensic significance of fresh traces of blood at the scene: drops, splashes, puddles, drips, blots, prints. The mechanism of formation. Blood sampling for laboratory research. Possibilities of laboratory diagnostics.
Traces of blood - they mean the presence of any amount of blood in the environment outside the human or animal body. Traces of dried blood on any carrier object are called stains.
Significance of blood traces: establishing the presence of blood, its species and group origin; conditions and mechanism of formation of blood traces.
Types of traces of blood on form and the education mechanism. In the description, we use the classification of elementary traces: 1) Stains from falling drops. A drop is called the minimum amount of liquid for these conditions, which took a rounded shape due to the cohesion of its particles. Drops from stationary objects fall vertically downward under the influence of gravity.
When falling on a horizontal smooth surface, the shape and size of the spot depend on the height of the fall. With a drop height of up to 10 - 15 cm, the spots have a round shape, up to 1 cm in diameter and smooth edges; when falling from a height of up to 40 - 50 cm, the diameter of the spot is 1.5 cm, the edges become jagged; at a drop height of up to 1.5-2 m, the spot diameter increases to 2 cm, secondary spattering appears, the edges have a ray-like shape.
When droplets fall from an object moving at a low speed, the form of a pear-shaped spot with thinning in the direction of motion, at a high speed of motion, the droplets are scattered onto the spray.
When drops fall on an inclined surface, the spot lengthens towards the inclination and its lower part has a greater thickness.
Spots from falling drops of blood are an indicator of bleeding. These traces help to determine the direction of movement of the wounded person or the transfer of a corpse, to identify the pace of movement, the place of stopping.
2) Splash stains. With additional kinetic energy, a drop of blood meeting
air resistance, breaks down into small droplets called splashes. Splash stains
differ in multiplicity and smaller sizes, up to point.
Splashes are formed when arterial bleeding, when hitting a bloody body or object, on accumulation of blood or soaking, when a corpse is dismembered, when a bloody object or weapon is shaken sharply. With arterial bleeding, spots are formed that are located in the form of chains with relatively equal intervals and sizes. If splashes arise from impacts on a bloody object, then a fan-shaped arrangement of spots is characteristic.
3) Leaks. These are traces of an elongated shape, formed when flowing down
blood on an inclined or vertical surface under the influence of gravity.
When the force of gravity of the flowing blood is balanced by the force of the surface
tension, the drip stops, forming the so-called clavate
thickening. On an uneven surface, the drips become sinuous.
Flows help to establish the position of the wounded person after the onset of bleeding, restore the position of the surrounding objects, and resolve the issue of the sequence of injuries.
4) Prints. Formed by static (non-slip) contact
a bloody tear-forming object with a lacrimal surface
(fingers, palms, feet, shoes, etc.).
5) Blots and strokes. Formed from sliding contact with
a bloody object, weapon, hands, etc.
6) Puddles. Formed with significant blood loss on horizontal
non-absorbent or wet-absorbent surfaces, in the absence of
body movement.
Preliminary tests:
s sample with 3% hydrogen peroxide;
h benzidine reaction (blue color of the solution);
h reaction with Voskoboinikov's reagent (powdered benzidine reagent, more convenient for storage and transportation);
h sample with luminol.
All preliminary blood tests are non-specific, a negative result of preliminary tests does not give the right to refuse the subsequent examination of suspicious blood stains in the laboratory.
According to our data, injuries of the anterior abdominal wall, not penetrating into, are found in 13.2-15.3% of all abdominal injuries. In some of the patients we observed, wounds with both cold weapons and firearms were clearly demonstrative in nature, like a “cry for help,” like a desperate attempt to attract the attention of others. Such wounds are often cut and although they have an outwardly dramatic appearance, they do not pose a threat to life, with rare exceptions when the lower epigastric artery is damaged.
significant portion lumbar injuries, without penetrating into the abdominal cavity, leads to damage to the organs of the retroperitoneal space. The most frequently observed damage is the kidneys, the ascending and descending colon, somewhat less often - the duodenum and pancreas, the aorta and the inferior vena cava.
Injuries to the anterior abdominal wall and the lumbar region, inflicted by projectiles at low velocity, do not present major problems for surgical treatment. When using high-speed projectiles, the effect of a combat strike is so severe that it leads to a life-threatening condition.
Non-penetrating wounds can be through (tangential), when the wound canal passes from right to left (or vice versa) in the thickness of the back muscles and in the retroperitoneal space, accompanied by the formation of hemorrhages of various sizes, with damage to the vertebrae and spinal cord.
Penetrating wounds of the abdominal wall
About 20-25% wounds with melee weapons penetrating into the abdominal cavity are not accompanied by damage to internal organs, even with deep immersion of a sharp object. Most often this occurs when a knife is struck with low force and speed, when the movable loops of the small and large intestine, due to elasticity, have time to slip away from the blade.
It should be noted that the presence postoperative scars and adhesions in the abdominal cavity, limiting the mobility of organs, sharply increases the possibility of their damage in case of penetrating stab and cut wounds.
Puncture wounds inflict bayonet, a narrow stylet, sharpened files and screwdrivers, an awl, a table fork and other sharp objects. Such wounds are characterized by small size, but significant depth of the wound channel.
At extensive cut wounds penetrating into the abdominal cavity, there is a prolapse of the abdominal organs, most often the greater omentum and loops of the small intestine. In the literature, there are observations of prolapse from wounds of the spleen, tail of the pancreas, and the left lobe of the liver.
At the same time, the organs that have fallen out are exposed to massive infection and can be impaired.
In a fictional description of a cut wound in the abdomen can be found in Hans Evers (collection of stories "Horror." A disgusting mass of intestines literally flowed from the long wound. It was the section of the liver that fell into the wound of the abdominal wall in the 12th century that was successfully removed with subsequent cauterization of the Hildanus parenchyma with a hot iron, initiating liver resections.
In car accidents and industrial injuries, there are injuries inflicted by secondary projectiles. Such wounds in nature are close to lacerated and bruised.
Skin wounds in most cases, they are localized on the anterior abdominal wall. In second place in frequency are wounds of the lower chest with the spread of the wound channel through the diaphragm into the abdominal cavity or retroperitoneal space. Blood, bile, liquid intestinal contents, urine can come from the wound of the abdominal wall. Much less often, wounds are localized in the lumbar, sacral or gluteal regions.
In observations F. Henao et al. with penetrating wounds of the lumbar region, the wound channel penetrated into the abdominal cavity in 60%, in the pleural cavity in 31%, and in 9% the wound had a thoracoabdominal character.
In a detailed message J. J. Peck, T.V. Berne emphasized that most often such wounds are located to the left of the spine; in 22% they have a punctured character with a narrow and long wound channel, the course of which in the muscle mass can be displaced. Information on the frequency of injuries to the abdominal cavity and retroperitoneal space is contradictory: in the literature, 5.8 to 75% are often cited.
Concerning gunshot wounds, then the morphological features of damage to the parenchymal organs are due to their homogeneous structure and abundant blood supply. Therefore, usually the wound channel in these organs has a forward direction, filled with detritus and blood clots. Cracks of varying depth extend from it in different directions.
Morphological features damage to hollow organs due to the fact that these organs differ sharply in the content of liquid and gases. It is due to the displacement of fluid and gases in the case of injuries of hollow organs that a temporary pulsating cavity of large dimensions arises, which leads to extensive ruptures and layering of the wall of the organs at a great distance from the wound channel. In this case, hollow organs filled with liquid content and gas are damaged much more strongly than hollow organs without content. This fact was well known even during the First World War, when the soldiers were given only sugar before the attack, forbidding the intake of abundant food and limiting the intake of fluids.
Determined that the presence of dense feces in the colon, to some extent reduces the degree of hydraulic lateral impact and, therefore, reduces the likelihood of extensive rupture. At the same time, the places of natural bowel curves and places of its fixation, making it difficult for the shock wave to pass along the intestinal tube, are typical places of rupture, which must be paid attention to when revising the abdominal organs.
Depending on the kinetic energy of the wounding projectile, it can pass through both walls of a hollow organ or stop in its lumen. In the latter case, the stopping effect of the wall of the hollow organ may be accompanied by its contusion, followed by necrosis. Contusions of hollow organs from the outside lead to the formation of subserous hematomas, which can also subsequently lead to necrosis of the deep-lying layers of the intestine.
In addition, the feature gunshot wounds to the abdomen is the so-called transformation of the external contours of the abdominal cavity [Aleksandrov LN and others], which consists in the fact that the transverse dimensions of the abdomen at the time of injury change dramatically in the direction of increase and decrease. These vibrations are repeated several times and with through wounds are accompanied by an intermittent release of the contents of the damaged hollow organs from the outlet, often ending in the loss of intestinal loops or a strand of the greater omentum from this opening.
A wound on the abdomen is a serious injury to the skin, soft tissues, and sometimes internal organs. In such cases, it is important to provide first aid in a timely manner. Further forecasts of the victim's life depend on this.
Symptoms and types of injuries
In case of a wound in the abdomen, you need to stop the blood with clean rollers.
Injuries are usually classified into two groups. It is imperative to pay attention to this when providing assistance, since not all actions are acceptable. A wound to the abdomen happens:
- Knife. Received as a result of a direct or oblique blow with a knife blade in the peritoneal region.
- Firearms. It occurs as a result of a shot from a pistol, gun, shotgun. May be cross-cutting. Sometimes multiple wounds are formed from a single shot.
Stab wounds of the abdominal cavity according to ICD (10) have individual codes depending on the stage. Injuries can be:
- Open (according to ICD S31). The blade has penetrated deep into the abdominal cavity. Loops of intestines and internal organs can be seen from the wound. The visible areas of the mucous membranes and the skin around the injured area acquire a pale shade, sometimes turn blue. The victim has difficulty breathing, develops bouts of vomiting.
- Closed (according to ICD S36). Formed when struck with a blunt blade, through outer clothing. With such a wound, the internal organs are not damaged. Only a bruise of soft tissues and a cut in the skin are possible. A non-penetrating wound is characterized by slight capillary bleeding, the occurrence of hematomas around the injury.
- Infected wounds of the anterior abdominal wall. They have fuzzy boundaries. The ingress of dirt is noticeable, suppuration appears, peritonitis develops.
- Uninfected injuries have clear boundaries. Internal organs are not affected.
A closed wound on the abdomen may be accompanied by internal bleeding, as evidenced by profuse cyanosis and tissue edema at the site of impact.
First aid
First aid for injury
Regardless of the complexity of the injury, the victim needs first aid. It must be performed in any situation. It is important to follow the rules for carrying out some manipulations so as not to harm the wounded.
- Call an ambulance first, then proceed with first aid.
- If the person is unconscious, tilt their head back and turn on their side. This will allow oxygen to enter the lungs unhindered. Vomit will be easily removed from the mouth.
- Treat open wounds with alcohol, hydrogen peroxide, Miramistin only from the outside. Never put antiseptics inside.
For any injury in the abdominal cavity, you must not feed and water the victim.
- If possible, fold the prolapsed internal organs together with wet hands in sterile gloves. Then place them in a clean bag or rag. If that fails, apply a bandage. To do this, form rollers from a clean cloth or gauze and put them around the wound, put a cloth on top of them.
- To prevent the internal organs from drying out, they need to be moistened regularly, sprinkle water on the fabric for 10-15 minutes.
- If an object sticks out of the wound, secure it. To do this, glue long bandage tapes on both sides of the impact site, then wrap them around the foreign object and fix the tapes again with adhesive tape. If you don't have a bandage on hand, use any long cloth.
- Never remove the wounding weapon from the wound. This can cause bleeding and death of the victim.
- Do not give antipyretics and pain relievers to the injured person. Such actions will hide the etiology of the injury.
- After first aid, make the victim a sitting position with your back against a wall or tree. Bend your legs at the knees.
- If the internal organs are not visible, be sure to clean the wound of dirt and treat it with an antiseptic. If this is not at hand, use any alcoholic beverage.
- After helping, fold a piece of bandage or gauze in 10 layers, moisten with water or peroxide and apply to the wound. Apply with plaster or tape to intact skin.
After providing first aid, it is necessary to stay close to the wounded until the arrival of the ambulance brigade. Doctors need to be told what actions were taken.
Regardless of whether the victim is conscious or not, first aid should be provided.
What is forbidden to do
Penetrating injury to the abdomen causes severe thirst in the victim. At this moment, he is forbidden to give drink. To relieve the condition, dampen a cloth with water and wipe your lips, temples and forehead. It is allowed to simply rinse the oral cavity. Any food is contraindicated.
The wounded must not be moved or attempted to be transported to another place. This can provoke pinching of internal organs, deeper penetration, opening of bleeding.
Is it possible to determine the picture of abdominal injuries
The general picture of stab-cut injuries of the abdominal cavity is determined by three states of the body: shock, organ perforation, the presence of bleeding. Also, the condition of the internal parts of the body can be assessed by the fluid flowing from the wound: bile, urea and others.
Accurate diagnosis in the absence of the listed symptoms is impossible. Only doctors can determine the condition of the victim. Diagnostics can be difficult due to the influence of weather conditions (heat, frost, precipitation).
Diagnostics and treatment
Anesthetic drug
A knife wound requires compulsory hospitalization. In most cases, the victim is assigned to surgery. Initially, a thorough diagnosis of the patient's condition is performed. The algorithm of actions is as follows.
For two to three months after the operation, heavy physical activity is prohibited. Otherwise, there is a risk of dehiscence of the scar at the site of injury.
Consequences of a knife wound
With the timely detection of abdominal injuries, the chances of a favorable prognosis for the victim's recovery increase. However, a penetrating or blunt wound can cause some complications. These include:
- Insufficiency of internal organs;
- Inflammation of the peritoneum and soft tissues;
- Sepsis (blood poisoning);
- Small intestine pathology;
- Internal bleeding.
After stab wounds with injured internal organs, the body recovers for a long time and requires lifelong maintenance therapy. Therefore, assistance to the victim must be provided promptly. In such cases, it is likely that the person will not be left disabled.
Open or penetrating wounds to the abdomen are most often inflicted with firearms or cutting and stabbing objects.
In the practice of surgeons from penetrating wounds of the abdomen, gunshot and stab-cut wounds are most often encountered. In these patients, the abdomen is examined immediately after airway patency and adequate breathing and circulation have been restored. Indications for performing laparotomy are set on the basis of signs of damage to internal organs that require surgical treatment. Emergency surgery is needed for patients in a state of shock and with signs of peritonitis, patients who bleed through a nasogastric tube or from the rectum, patients who have found free gas in the abdominal cavity or in the retroperitoneal space, patients who have internal organs are visible, as well as those who were taken to the hospital with a knife sticking in the stomach. In such cases, intravenous urography (IVP) is urgently performed, which can quickly identify the presence of two functioning kidneys. Intravenous urography is performed not so much to detect damage to the organs of the urinary system, but to make sure that the kidney on the intact side is functioning well (extremely necessary information in cases when the question of performing a nephrectomy arises during surgery).
Diagnosis in patients with gunshot wounds is fairly straightforward. On the contrary, the penetrating nature of stab wounds is more difficult to establish. In the following, these two types of penetrating abdominal injuries will be described.
Gunshot wounds, in which a projectile penetrates the body from the chest to the thighs, can cause damage to the abdominal organs. Of all penetrating gunshot wounds to the abdomen, 98% cause damage to internal organs, which requires immediate surgical intervention. However, in some cases, the nature of the gunshot wound can cause doubts among doctors. This situation occurs mainly with tangential gunshot wounds to the abdomen. In such cases, laparocentesis is performed, and if, when examining the fluid obtained from the abdominal cavity during peritoneal lavage, erythrocytes of more than 10.0 × 1012 / l are found, the wound is penetrating and an urgent laparotomy is required. Gunshot wounds to the thoracoabdominal region, back, lateral abdomen and pelvic region, which cause doubts among doctors about their penetrating nature, are quite rare. In such cases, the diagnostic tactics should be the same as for stab and cut wounds of the abdomen.
With stab and cut wounds of the anterior abdominal wall, the tactics of doctors may be different. It is always important to remember that only 50% of all stab wounds in the abdomen penetrate into the abdominal cavity, and only 50% of them cause damage to internal organs that require urgent surgical intervention. In our opinion, the main task of examining such patients is to identify victims who have indications for urgent surgery. Such patients need to be prepared quickly for surgery. Patients who are conscious and with stable hemodynamic parameters can be examined several times in dynamics so as not to miss a penetrating wound. If they show signs of developing peritonitis or shock, it is necessary to perform surgery. All other patients can be discharged from the hospital in 24-48 hours. Examples when during dynamic observation and examination there are doubts about the diagnosis are quite rare. In these cases, many authors recommend using all possible diagnostic techniques, including laparocentesis and peritoneal lavage, local examination of the wound (surgical debridement and revision), diagnostic laparoscopy, and, finally, diagnostic laparotomy. Of all these techniques, in our opinion, laparocentesis and peritoneal lavage are the most informative for diagnosing a penetrating injury to the abdomen and for setting indications for urgent surgery. There are three types of stab wounds in the abdomen that present significant diagnostic difficulties. These are thoracoabdominal wounds, injuries of the back and lateral abdomen. With thoracoabdominal wounds, the wound canal can enter the chest and penetrate through the diaphragm into the abdominal cavity. In this case, abdominal organs can often be damaged. The presence in such patients of signs of wound penetration into the abdominal cavity is an indication for urgent surgery. When examining these cases, we used laparocentesis and peritoneal lavage. The presence of more than 10.0 × 1012 / l of erythrocytes in the fluid coming from the abdominal cavity was evidence of the penetrating nature of the injury. In such cases, drainage of the pleural cavity and laparotomy were performed, during which the defect in the diaphragm was sutured, and then adequate surgical intervention, depending on the lesions found in the abdominal cavity. Stab and cut wounds of the back and lateral parts of the abdomen can cause damage to the organs of the retroperitoneal space and the abdominal cavity. Especially dangerous are injuries of the retroperitoneal part of the duodenum and colon. We also used laparocentesis and peritoneal lavage in these patients. The presence of more than 10.0 × 1012 / l of erythrocytes in the fluid coming from the abdominal cavity indicates the penetrating nature of the injury. In such cases, an emergency laparotomy was performed to repair the damage to the abdominal and retroperitoneal organs. If the content of erythrocytes in the fluid obtained from the abdominal cavity during peritoneal lavage was less than 10.0 × 1012 / L, we performed computed tomography of the abdomen with the introduction of a contrast agent intravenously, into the duodenum and into the colon. With this technique of computed tomography with "triple" contrast, the accuracy of the method in diagnosing damage to the organs of the retroperitoneal space is more than 95%. Stab and cut wounds of the pelvis can cause damage to the organs of the gastrointestinal tract, organs of the urinary tract, as well as internal genital organs in women. We also used laparocentesis and peritoneal lavage to identify the penetrating nature of the injury. In addition, all patients with stab and cut wounds of the pelvic region underwent rigid proctosigmoidoscopy (recto-romanoscopy), cysto-urethrography, and women, in addition, underwent a vaginal examination in the speculum. Moreover, if the content of erythrocytes in the fluid obtained from the abdominal cavity exceeded 10.0 × 1012 / L, or during other studies, signs of damage to internal organs were detected, an urgent operation was performed. All other patients were followed up.
Most often, with penetrating stab-cut wounds of the abdomen from the parenchymal organs, the liver (in 37% of cases), the spleen (7%) and the kidneys (5%) are damaged. However, in general, hollow organs are most often damaged with stab-cut penetrating wounds of the abdomen. Their hollow organs most often damage the small intestine (in 26% of cases), the stomach (19%) and the large intestine (16.5%).
Combine the properties of piercing and cutting. Naturally, the damage from them will combine the signs of both stab and cut wounds.
A stab wound has the following elements: an inlet in the skin, a wound channel extending from it in tissues or organs and, sometimes, if the wound is through, then an outlet wound opening. Stab and cut wounds have their own characteristic features that make it possible to distinguish these wounds from both cut and stab wounds.
- The form of stab wounds can be slit, fusiform, arcuate, angular. The most common are fusiform and slit wounds. If a tool with a one-sided blade sharpening was in operation, then the greatest divergence of the edges will be at the edge where the butt of the gun acted. Wounds from tools with a more or less thick back (more than 2 mm) are U-shaped (for example, from Finnish knives) may have a wedge-triangular shape. In those cases when the tool, when removing it from the wound, rotates around its axis, there is, in addition to the main, an additional incision and one of the ends of the wound takes the form of a "dovetail".
- The edges of stab wounds are usually even, without sedimentation or with slight sedimentation, respectively, the area of action of the butt. If the blade of the knife was covered with rust or dirty, then a rubdown belt remains on the skin edges of the wound. When examining the edges of such a wound by the method of colored prints, traces of the metal from which the blade of the weapon is made can be found.
- The shape of the ends of the wounds in cases where the tool (dagger) had a double-sided sharpening in the form of an acute angle. With one-sided sharpening of the tool, one end of the wound is sharp, and the other from the butt is rounded or U-shaped, sometimes with small tears or notches from the action of the butt ribs.
- The wound canal in more or less dense tissues has a slit-like shape, its walls are even and smooth, fatty lobules of subcutaneous tissue can protrude into the lumen of the wound canal. The length of the wound channel will not necessarily correspond to the length of the blade of the tool: the blade may not be fully immersed in the body, then the depth of the wound channel will be less than the length of the blade of the tool. When such a pliable part of the body is injured, such as the abdomen, the blade of the tool can be completely immersed in the wound and, when pressed, the anterior abdominal wall can be fed posteriorly. In such cases, after removing the weapon from the wound, it may turn out that the depth of the wound channel will be greater than the length of the blade of the injury weapon.
The length of the skin wound also does not give grounds for judging the width of the blade of the injury tool, since the blade can be immersed in the body and removed from it not in the same position, but move in the tissues along the length of the wound and its length will be in these cases greater than the width of the injury tool.
In such dense tissues as cartilage, traces of sliding of the blade of the tool in the form of parallel ridges and grooves from the irregularities of the blade can form on the walls of the wound channel. These traces are strictly individual and can be used to identify a specific specimen of the weapon of injury. With a strong impact with the end (tip) of a piercing-cutting tool on a flat bone at an angle of 90 ° or close to it, the bone can be damaged - a perforated fracture occurs, the shape and dimensions of which (from the side of the outer plate) practically correspond to the shapes and sizes of the cross-section of the blade of the injuring tool at the level of its immersion in the bone.
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