Due to anatomical features breast organs, with penetrating wounds, the lungs are most often (70-80%) damaged. In the pathogenesis of vital disorders, pneumothorax comes to the fore with the exclusion of the large alveolar surface from the function of external respiration. Tension pneumothorax leads to displacement of the mediastinum with disruption of blood flow through the large vessels of the chest.
Lung damage from stab wounds most often localized in the lower sections: on the left - on the anterolateral surface of the lower lobe (V, less often IV segments, as well as VII, VIII and IX segments), on the right - on the posterolateral surface of the middle and lower lobes (VII, VIII, IX segments, less often - IV, V and VI segments).
The wound channel in the lung with stab wounds can be blind, through and tangential (tangential).
Blind injuries Depending on the depth, they are divided into superficial and deep. The criteria for such division are very relative; in a 2005 publication, we divided stab wounds of the lungs into superficial (up to 5 mm deep), shallow (from 5 to 15 mm) and deep (more than 15 mm). However, this division was used in relation to the possibilities of thoracoscopic interventions for chest wounds, and therefore was of a private nature.
More significant is localization of stab wounds. Their location in the peripheral zone of the lung (regardless of whether they are blind or through) is not accompanied by heavy bleeding or the entry of air into the pleural cavity. Injury to the superficial layers of lung tissue leads to moderate bleeding, which quickly stops on its own. Wounds of the hilar zone of the lungs, on the contrary, are often accompanied by damage to the vascular network of the lungs and the bronchial tree, which makes them very dangerous.
For stab wounds of the lung Characteristic is a slit-like shape with smooth edges and moderate bleeding. In case of a deep wound, due to the obstructed outflow of blood from the wound channel, hemorrhagic impregnation occurs in the circumference. With penetrating gunshot wounds of the chest, only 10% of the wounding projectile passes through the pleural sinuses, bypassing the lung. In the remaining 90%, the lung tissue is damaged to one degree or another.
Gunshot wounds of the lung divided into through, blind and tangent. Damage to the great vessels and large bronchi, according to military field surgeons, does not occur often. However, we believe that the wounded with such injuries die faster than they are in the field of view of surgeons.
Porous and elastic lung tissue, which offers little resistance to the wounding projectile, is damaged only in the immediate vicinity of the wound channel. Bullet wounds in the lung parenchyma form a channel with a diameter of 5 to 20 mm, filled with blood and detritus. When the ribs are damaged, small fragments of them are often located in the wound channel, as well as infected (contaminated) foreign bodies - scraps of clothing, parts of a wad (in case of a shot wound), fragments of bullet casings.
In a circle wound channel after a few hours, fibrin falls out, which, together with blood clots, fills the wound channel, stopping air leakage and bleeding. The zone of traumatic necrosis around the wound drip does not exceed 2-5 mm, the zone of molecular concussion with a diameter of 2-3 cm is represented by thrombosis of small blood vessels and hemorrhages into the lung tissue. Focal hemorrhages and ruptures of the interalveolar septa lead to the occurrence of atelectasis.
In a significant number of observations, with a smooth course, hemorrhage into the lung tissue resolves within 7-14 days.
However, when wounded by high-velocity bullets extensive ruptures and crushing of the pulmonary parenchyma occur. In this case, fragments of damaged ribs, which have received high kinetic energy, cause additional numerous damage.
In the vast majority of observations for lung injuries hemopneumothorax immediately appears, the volume of hemothorax depends on the caliber and number of damaged blood vessels, and the volume of pneumothorax depends on the caliber and number of damaged airways.
Extensive destruction of the lung parenchyma observed with shrapnel wounds and mine-explosive trauma. Shell and mine fragments form irregularly shaped wound channels with tissue crushing, depending on the size of the fragment and the speed with which it penetrated the body.
Sometimes whole share or even most of the lung are areas of broken tissue soaked in blood. Such traumatic hemorrhagic infiltration, with a favorable course of the post-traumatic period, is organized over time with the outcome of fibrosis. But much more often the process occurs with necrosis, infection and the formation of lung abscesses.
One of the first publications of a successful outcome with abscess formation of lung tissue after a gunshot wound belongs to N.I. Pirogov. He cites the case of the Marquis De Ravagli, who, 10 years after a gunshot wound to his lung, had a wad of tow come out with cough and pus, which caused the formation of an abscess.
Of the 1218 patients admitted to Institute with lung injuries, 1064 (87.4%) had stab wounds, 154 (12.6%) had gunshot wounds. The vast majority of the wounded had stab wounds to the superficial layers of the parenchyma (915 observations, accounting for 75.1%). However, in 303 (24.9%) the depth of the wounds was 2 cm or more, including in 61 (5%) reaching the hilar zone and the root of the lung. When analyzing this group of victims, it was revealed that left-sided injuries predominated (171 victims, accounting for 56.4%). Injuries to the right lung were noted in 116 (38.3%), bilateral wounds were present in 16 victims (5.3%). In 103 patients in this group, the wounds were of a gunshot nature, and in 56 (54.4%) they were blind, in 47 (45.6%) - through.
Length of wound channels 303 victims are presented in the table, while the number of wounds exceeds the number of observations due to multiple lung injuries. The table shows that the length of the wound channel in our observations ranged from 2 to 18 cm, including wounds with cold steel. In more than 50% of cases, the length of the wound channel was 4-8 cm.
From the table it follows that the victims with established lung injury Most often, there were simultaneous injuries to the vessels of the chest wall, diaphragm and heart.
Quite often there were rib damage, including injuries from cold steel. Damage to the thoracic vertebrae and spinal cord occurred only with gunshot wounds.
From the abdominal organs simultaneously with a lung injury Injuries to the liver and stomach were most often observed. Of the combined injuries, most often there were injuries to the upper and lower extremities.
Lung injuries according to the OIS scale are distributed as follows (the volume of hemothorax is not taken into account here):
The presence of bilateral injuries increases the severity of the I-II degree injury by one more degree.
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 severe bleeding and valvular or open pneumothorax occurs.
These symptoms are very dangerous for maintaining the life of the victim.
They can cause complications that require urgent surgical intervention.
In case of a bullet wound to the lungs, when the victim has a closed chest injury, 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 closed pneumothorax, 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 large gauze napkin folded many times is placed on top of it. 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 performing a vagosympathetic blockade according to Vishnevsky on the side that was injured will be very effective.
Video
Penetrating trauma
Symptoms of penetrating are 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:
- First, you should make sure that there is no foreign object in the wound.
- Then you need to press your palm against the damaged area to limit the flow of air.
- If the victim has a through wound, the exit and entrance holes to the wound should be closed.
- Then you should cover the damaged area with material that allows air to pass through and secure it with a bandage or plaster.
- The patient should be placed in a semi-sitting position.
- It is necessary to apply something cold to the wound site, but first apply a pad.
- 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.
- 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. Often the chest is injured when they fall from a height, during a beating, a sharp simultaneous or numerous short-term or long-term squeezing of a patient in a crowd of people or rubble.
Closed form
- Promedol or analgin should be administered intramuscularly.
- Inhalation anesthesia with nitrous oxide and oxygen.
- Oxygen therapy for pain relief.
- 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.
- 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.
- Any medications for the heart are effective. Antishock agents can be used.
- After assistance has been provided, the patient should be taken to a medical facility.
- 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, different degrees of severity are distinguished. It is not easy to see a small, closed, minor chest wound.
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
Due to anatomical features breast organs, with penetrating wounds, the lungs are most often (70-80%) damaged. In the pathogenesis of vital disorders, pneumothorax comes to the fore with the exclusion of the large alveolar surface from the function of external respiration. Tension pneumothorax leads to displacement of the mediastinum with disruption of blood flow through the large vessels of the chest.
Lung damage from stab wounds most often localized in the lower sections: on the left - on the anterolateral surface of the lower lobe (V, less often IV segments, as well as VII, VIII and IX segments), on the right - on the posterolateral surface of the middle and lower lobes (VII, VIII, IX segments, less often - IV, V and VI segments).
The wound channel in the lung with stab wounds can be blind, through and tangential (tangential).
Blind injuries Depending on the depth, they are divided into superficial and deep. The criteria for such division are very relative; in a 2005 publication, we divided stab wounds of the lungs into superficial (up to 5 mm deep), shallow (from 5 to 15 mm) and deep (more than 15 mm). However, this division was used in relation to the possibilities of thoracoscopic interventions for chest wounds, and therefore was of a private nature.
More significant is localization of stab wounds. Their location in the peripheral zone of the lung (regardless of whether they are blind or through) is not accompanied by heavy bleeding or the entry of air into the pleural cavity. Injury to the superficial layers of lung tissue leads to moderate bleeding, which quickly stops on its own. Wounds of the hilar zone of the lungs, on the contrary, are often accompanied by damage to the vascular network of the lungs and the bronchial tree, which makes them very dangerous.
For stab wounds of the lung Characteristic is a slit-like shape with smooth edges and moderate bleeding. In case of a deep wound, due to the obstructed outflow of blood from the wound channel, hemorrhagic impregnation occurs in the circumference. With penetrating gunshot wounds of the chest, only 10% of the wounding projectile passes through the pleural sinuses, bypassing the lung. In the remaining 90%, the lung tissue is damaged to one degree or another.
Gunshot wounds of the lung divided into through, blind and tangent. Damage to the great vessels and large bronchi, according to military field surgeons, does not occur often. However, we believe that the wounded with such injuries die faster than they are in the field of view of surgeons.
Porous and elastic lung tissue, which offers little resistance to the wounding projectile, is damaged only in the immediate vicinity of the wound channel. Bullet wounds in the lung parenchyma form a channel with a diameter of 5 to 20 mm, filled with blood and detritus. When the ribs are damaged, small fragments of them are often located in the wound channel, as well as infected (contaminated) foreign bodies - scraps of clothing, parts of a wad (in case of a shot wound), fragments of bullet casings.
In a circle wound channel after a few hours, fibrin falls out, which, together with blood clots, fills the wound channel, stopping air leakage and bleeding. The zone of traumatic necrosis around the wound drip does not exceed 2-5 mm, the zone of molecular concussion with a diameter of 2-3 cm is represented by thrombosis of small blood vessels and hemorrhages into the lung tissue. Focal hemorrhages and ruptures of the interalveolar septa lead to the occurrence of atelectasis.
In a significant number of observations, with a smooth course, hemorrhage into the lung tissue resolves within 7-14 days.
However, when wounded by high-velocity bullets extensive ruptures and crushing of the pulmonary parenchyma occur. In this case, fragments of damaged ribs, which have received high kinetic energy, cause additional numerous damage.
In the vast majority of observations for lung injuries hemopneumothorax immediately appears, the volume of hemothorax depends on the caliber and number of damaged blood vessels, and the volume of pneumothorax depends on the caliber and number of damaged airways.
Extensive destruction of the lung parenchyma observed with shrapnel wounds and mine-explosive trauma. Shell and mine fragments form irregularly shaped wound channels with tissue crushing, depending on the size of the fragment and the speed with which it penetrated the body.
Sometimes whole share or even most of the lung are areas of broken tissue soaked in blood. Such traumatic hemorrhagic infiltration, with a favorable course of the post-traumatic period, is organized over time with the outcome of fibrosis. But much more often the process occurs with necrosis, infection and the formation of lung abscesses.
One of the first publications of a successful outcome with abscess formation of lung tissue after a gunshot wound belongs to N.I. Pirogov. He cites the case of the Marquis De Ravagli, who, 10 years after a gunshot wound to his lung, had a wad of tow come out with cough and pus, which caused the formation of an abscess.
Of the 1218 patients admitted to Institute with lung injuries, 1064 (87.4%) had stab wounds, 154 (12.6%) had gunshot wounds. The vast majority of the wounded had stab wounds to the superficial layers of the parenchyma (915 observations, accounting for 75.1%). However, in 303 (24.9%) the depth of the wounds was 2 cm or more, including in 61 (5%) reaching the hilar zone and the root of the lung. When analyzing this group of victims, it was revealed that left-sided injuries predominated (171 victims, accounting for 56.4%). Injuries to the right lung were noted in 116 (38.3%), bilateral wounds were present in 16 victims (5.3%). In 103 patients in this group, the wounds were of a gunshot nature, and in 56 (54.4%) they were blind, in 47 (45.6%) - through.
Length of wound channels 303 victims are presented in the table, while the number of wounds exceeds the number of observations due to multiple lung injuries. The table shows that the length of the wound channel in our observations ranged from 2 to 18 cm, including wounds with cold steel. In more than 50% of cases, the length of the wound channel was 4-8 cm.
From the table it follows that the victims with established lung injury Most often, there were simultaneous injuries to the vessels of the chest wall, diaphragm and heart.
Quite often there were rib damage, including injuries from cold steel. Damage to the thoracic vertebrae and spinal cord occurred only with gunshot wounds.
From the abdominal organs simultaneously with a lung injury Injuries to the liver and stomach were most often observed. Of the combined injuries, most often there were injuries to the upper and lower extremities.
Lung injuries according to the OIS scale are distributed as follows (the volume of hemothorax is not taken into account here):
The presence of bilateral injuries increases the severity of the I-II degree injury by one more degree.
Injuries to the pleura and lungs are divided into closed and open. Closed are injuries that occur without violating the integrity of the skin, open are injuries that are accompanied by a violation of their integrity, i.e., wounds.
OPEN DAMAGES (WOUNDS) OF THE PLEURA AND LUNGS
Injuries to the pleura and lungs are one of the types of penetrating chest injuries. In peacetime, these injuries are rare. In wartime their number increases greatly. Among gunshot wounds of the chest, a distinction is made between tangential, often accompanied by rib fractures, through and blind. These injuries are very complex and unique and require special consideration.
The pleura is rarely injured in isolation. Isolated damage to the pleura is possible with tangential wounds or with injuries to the spare pleural spaces (sinuses) during exhalation while they are free from the lungs. Injuries to the pleura are almost always combined with injuries to the lung.
Injuries of the pleura and lungs are characterized by some peculiar phenomena: accumulation of blood in the pleural cavity - hemothorax, entry of air into the pleural cavity - pneumothorax and air infiltration of the periwound tissue - traumatic emphysema.
1. Hemothorax ( haemothorax) . The source of bleeding into the pleural cavity is usually the pulmonary vessels, less often the vessels of the chest wall (intercostal, a. mammaria interna) and phrenic and, even more rarely, great vessels of the mediastinum and heart.
The amount of blood flowing into the pleural cavity primarily depends on the caliber of the damaged vessel. Negative pressure in the difficult cavity, exerting a suction effect, maintains bleeding. The volume of hemothorax, in addition, increases due to concomitant aseptic exudation (hemopleuritis). A large hemothorax in the amount of 1,000-1,500 ml strongly compresses the lung and pushes the mediastinum with non-organs enclosed in it to the opposite side. The latter leads to significant difficulty in blood circulation and breathing and sometimes ends in death (Fig. 78). As for the immediate fate of the blood spilled into the pleural cavity, then, according to the observations of B. E. Linberg and other Soviet surgeons conducted during the Great Patriotic War, the blood in the pleural cavity remains liquid for a long time.
Blood poured into the pleural cavity loses its ability to clot after 5 hours. A test is based on this fact to determine whether bleeding into the pleural cavity has stopped. If the liquid blood of a hemothorax, obtained by puncture more than 5 hours after the injury, does not clot, then the bleeding can be considered to have stopped. If the blood clots, the bleeding continues.
Subsequently, the liquid part of the blood is absorbed, clots are organized and the pleural cavity is obliterated, or the hemothorax becomes infected, and the most severe complication of hemothorax develops - pleural empyema. Microbes enter the pleural cavity through an external wound or from the side of the lung from a damaged bronchus. Microbes are especially often introduced by a foreign body. Therefore, infected hemothorax is a common accompaniment of blind lung wounds. It is also possible that the infection can enter hematogenously from a purulent focus existing in the body.
Clinical picture of hemothorax. Symptoms of hemothorax are signs of internal bleeding, dull sound when tapping, movement of dullness of the heart due to displacement of the mediastinum, expansion of the lower part and smoothing of the intercostal spaces of the corresponding half of the chest, disappearance or weakening of respiratory sounds when listening, absence of vocal tremor. Small hemothorax in the amount of 150-200 ml, which fits in the spare pleural space, is not detected by tapping, but is recognized radiographically. With significant hemothorax, the patient experiences pallor with a bluish tint, anemia, difficulty breathing, etc.
The accumulation of blood in the pleural cavity due to exudation initially increases for several days, and then, due to resorption, gradually decreases.
Recognition of hemothorax is completed by a test puncture and x-ray examination.
A rapid increase in the level of dullness during the first or second day after injury, especially accompanied by pallor of the patient and increased and weakened pulse, indicates resumption of bleeding. Absorption of uninfected hemothorax lasts about three weeks or longer and is accompanied by a moderate increase in temperature.
When hemothorax suppurates due to inflammatory exudation, the level of dullness increases, temperature and leukocytosis rise, ROE accelerates and the general condition worsens. The diagnosis of suppuration is made on the basis of test puncture data.
In doubtful cases, N.N. Petrov’s test can be used to distinguish aseptic hemothorax from an infected one. A certain amount of blood from the pleural cavity obtained by puncture is poured into the test tube and diluted with a fivefold amount of distilled water. In uninfected blood, after 5 minutes complete hemolysis occurs and the liquid becomes clear. If there is pus in the blood, the liquid remains cloudy, with a flaky sediment. Determining the quantitative ratio of leukocytes and erythrocytes contained in the extracted blood can also help in this regard. The normal ratio is 1: 600-1: 800. A ratio of 1: 100 and below indicates suppuration.
2. Pneumothorax ( pneumothorax) is formed due to entry into the pleural cavity, which has negative air pressure before opening. The wound opening that allows air to pass through can be located in the outer wall of the chest or in the bronchus. In accordance with this, a pneumothorax is distinguished, open outward and open inward. With a free pleural cavity, if a sufficient amount of air enters it, the lung collapses completely. In those cases when there are adhesions between the pleural layers, the lung partially collapses. If the penetrating wound hole is within the adhesions, pneumothorax does not form.
There are three types of pneumothorax: closed, open and valvular.
A closed pneumothorax is an accumulation of air in the pleural cavity that does not have, or, more precisely, has lost communication with the outer space or bronchus, since the wound channel has closed. With an open pneumothorax, the connection between the pleural cavity and the external space, due to the continued gaping of the wound channel, remains. Valvular pneumothorax is a pneumothorax open inward (into the bronchus) with such an arrangement and shape of the wound channel in which the air entering the pleural cavity during inhalation cannot escape back when exhaling (Fig. 79). The wound channel in the chest wall is closed.
Closed pneumothorax does not cause any significant respiratory distress, since the collapse of one lung is sufficiently compensated by the increased activity of the other and shortness of breath is almost not felt. Within a few days, the air contained in the pleural cavity and the effusion caused by the entry of air are absorbed without a trace.
A pneumothorax open to the outside with a large wound opening that exceeds the lumen of the main bronchus causes severe shortness of breath, cyanosis, and usually a decline in cardiac activity. Several factors play a role in the origin of shortness of breath. The first is loss of respiratory function of the collapsed lung. However, this factor is not the main one. An example of a closed pneumothorax shows that the collapse of one lung is sufficiently compensated by the increased activity of the other. A more significant role is played by the second factor - a shift to the healthy side of the mediastinum, which causes bending and compression of the large blood vessels of the mediastinum and thereby impedes blood circulation. An even greater influence is exerted by respiratory vibrations of the mediastinum, which protrudes either towards the pneumothorax - during inhalation, or in the opposite direction - during exhalation. Oscillatory movements of the mediastinum cause reflex irritation of the nerve nodes and plexuses of the mediastinum, which can cause shock.
The third factor is the pendulum-like movement of air containing an increased amount of carbon dioxide from one lung to another, preventing the flow of fresh air from the outside. The “spoiled” air exhaled from a non-collapsed lung partially enters the collapsed lung, and when inhaled, flows back into the healthy lung.
Air, which enters the pleural cavity in large quantities during an open pneumothorax and is continuously exchanged, has an adverse effect on the pleura, subjecting it to cooling and irritating the nerve endings in the pleura and the nerve centers of the root of the lung, which can cause pleural shock.
With a wide wound channel, along with the incoming air and the dust and blood splashes it brings from the surface of the skin, microbes inevitably penetrate into the pleural cavity. With a narrow wound channel, the entry of air into the pleural cavity is accompanied by a whistling sound (“sucking pneumothorax”).
Pneumothorax, open to the outside, with a small wound hole in the chest wall (with a diameter of less than half of the main bronchus), in terms of the degree of respiratory dysfunction, approaches a closed pneumothorax and, moreover, the smaller the wound hole, the larger it is.
A pneumothorax that opens into the bronchus is often valvular. Valvular (tension) pneumothorax is a particularly severe type of pneumothorax. The progressive accumulation of air in the pleural cavity that occurs during valve pneumothorax is apparently caused not so much by the formation of a valve in the wound canal, but by the fact that the narrow wound canal, due to the expansion of the lung, opens during inhalation and collapses during exhalation, and thus the reverse exit of air becomes impossible (see Fig. 79). The amount of air in the pleural cavity, penetrating with each breath, quickly reaches a maximum. The air strongly compresses the lung and displaces the mediastinum. In this case, the mediastinum and the large vessels located in it are bent and compressed with particular force. In addition, the suction activity of the chest cavity, which is of great importance for blood circulation, sharply weakens or stops. As a result, blood circulation and breathing are disrupted and severe, rapidly progressing shortness of breath occurs, sometimes ending in suffocation of the wounded.
Right-sided pneumothorax is more severe than left-sided pneumothorax. As experiments and clinical observations have shown, bilateral pneumothorax is not absolutely fatal.
Clinical picture of pneumothorax. Symptoms of pneumothorax are: a feeling of tightness in the chest, shortness of breath of varying strength depending on the form of pneumothorax, pallor and cyanosis of the face in severe cases, especially in the valvular form, a high-pitched tympanic sound when tapping, a shift of cardiac dullness to the healthy side, absence of vocal tremor, greater translucency of the sore side during x-ray examination.
In the vast majority of cases, hemothorax and pneumothorax are combined. With hemopneumothorax in the lower part of the chest, tapping produces a dull sound, in the upper part it produces a tympanic sound. Concussion of the chest causes splashing (see below for treatment of pneumothorax).
3. Traumatic emphysema often accompanies injuries to the pleura and lungs. Usually air infiltrates the subcutaneous tissue, and then emphysema is called subcutaneous. Less often, air penetrates the tissue of the mediastinum, and then emphysema is called mediastinal.
Air enters the subcutaneous tissue of the chest wall almost exclusively from the affected lung, extremely rarely through a chest wound, and then in small quantities. In the first case, with a free pleural cavity, the appearance of subcutaneous emphysema is preceded by pneumothorax and air penetrates into the subcutaneous tissue through an opening in the parietal layer of the pleura.
When there are pleural adhesions in the wound area, air enters the subcutaneous tissue directly from the lung, bypassing the pleural cavity. Usually, subcutaneous emphysema occupies a small area around the wound and quickly disappears, but sometimes, especially with valvular pneumothorax, subcutaneous emphysema reaches large sizes, covers a significant part of the body, spreads to the neck and face, while remaining superficial (Fig. 80). Increasing traumatic emphysema usually develops with valvular pneumothorax.
When infiltrating deep tissue located along the bronchi and subpleurally, air penetrates into the tissue of the mediastinum and compresses the organs contained therein, primarily the large veins, and causes deep disturbances in breathing and circulation, sometimes ending in death. With mediastinal emphysema, air, spreading through the pretracheal tissue, appears at the base of the neck, in the jugular and supraclavicular fossa.
Traumatic emphysema is easily recognized by a characteristic crunching sound, crepitus, felt when pressing on the skin. A significant air content in the subcutaneous tissue can be detected by tapping, which gives a tympanic tint, as well as radiographically.
Anaerobic gas phlegmon is sometimes mistaken for subcutaneous emphysema. With gas phlegmon, in addition to crepitus, there is a bronze coloration of the skin and a very serious general condition. In addition, gas infection does not develop immediately after injury. Subcutaneous emphysema itself has almost no effect on the general condition of the patient, even if it spreads over a very large extent. With mediastinal emphysema, there is moderate crepitus in the jugular and supraclavicular fossa, a tympanic sound on the sternum when tapped, and a spotty clearing of the shadow on an x-ray of the sternum.
When the lungs are injured, the air contained in the chest cavity and under pressure sometimes penetrates into the damaged veins of the lung, and from there into the vessels of the systemic circulation. When the patient is in an upright position, air can enter the small cerebral arteries and cause a cerebral air embolism. Clinically, cerebral embolism is manifested by a sudden loss of consciousness, which either passes or ends in death. Depending on the location of the emboli, one or another focal brain symptoms may be observed.
Stab wounds of the chest wall and lungs produce a smooth wound channel that heals quickly and easily if the bronchus or large blood vessel has not been significantly damaged. Gunshot wounds at certain distances and wounds from small fragments of explosive shells also produce a narrow, easily healing wound channel.
Bullet wounds at close range, wounds from large bullets, explosive bullets or large fragments of explosive shells produce larger, more complex and therefore more difficult to heal wounds. The wound channel often contains foreign bodies (bullets, shell fragments, pieces of clothing, etc.).
The general clinical picture of wounds of the pleura and lungs consists of symptoms of a general and local nature.
General phenomena include: cough, pallor of the mucous membranes and skin, coldness of the extremities, rapid and small pulse, shallow breathing, i.e., the phenomena of shock and acute anemia. Because these symptoms are caused by shock, they are transient and in most cases disappear after 3-4 hours. Their further continuation or intensification indicates internal bleeding. Unlike acute anemia, shock is characterized by an increased content of red blood cells in the blood.
Local phenomena, in addition to the wound, include hemothorax, pneumothorax, traumatic emphysema, and in case of lung damage, hemoptysis. The symptomatology of hemothorax, pneumothorax and traumatic emphysema is described above. As for the wound itself, the location of the entrance and exit (if any) openings and the nature of the wound are of paramount importance. The location of the wound openings is oriented towards the area of damage.
With a small wound opening and a narrow wound channel, the gap in the chest wall collapses, the pleural cavity closes and a hemothorax of greater or lesser magnitude remains in it, as well as a closed, soon disappearing pneumothorax. There is little or no shortness of breath. It is more significant only with abundant hemothorax. With a narrow but gaping wound hole, air is sucked into the pleural cavity with a whistle and an open pneumothorax is formed, which causes significant shortness of breath.
With a wide wound channel in the chest wall, air mixed with foamy blood, when breathing, either noisily enters the pleural cavity, introducing infection, or is noisily thrown out. A wide-open pneumothorax is accompanied by severe shortness of breath.
The main symptom of lung injury is hemoptysis, which may be the only clinical symptom of lung injury. The absence of hemoptysis does not prove the absence of lung injury. The same applies to pneumothorax. Hemoptysis usually lasts 4-10 days, and if there is a foreign body in the lung, it often lasts much longer. The respiratory movements of the chest on the side of the wound are limited, the abdominal muscles on the same side are reflexively tense due to damage or irritation of the intercostal nerves.
For blind wounds, fluoroscopic examination is required to detect and determine the location of foreign bodies. It is forbidden to examine the wound with a probe or finger, since this can easily introduce infection into an uninfected wound, and make a non-penetrating wound penetrating
Injuries to the lung are sometimes complicated by secondary bleeding, which can be fatal, as well as secondary pneumothorax, which is formed as a result of the secondary opening of a wound channel previously closed by surgery. A later, frequent and dangerous complication of penetrating chest wounds is infection in the form of pleural empyema, suppuration along the wound canal, pulmonary abscess, rarely lung gangrene, and later bronchial fistulas.
The prognosis for injuries to the pleura and lung is serious. The main causes of death are blood loss, asphyxia and infection.
Wounds with a narrow, easily collapsible wound channel, which are better able to resist infection, allow for incomparably more encouraging predictions than wide gaping wounds.
Treatment for injuries to the pleura and lungs has three main goals: stopping bleeding, restoring the normal breathing mechanism and preventing infection.
Minor bleeding from the external wound is stopped by applying a light pressure bandage. For a small, “pinpoint” hole as a result of a wound from a small-caliber rifle bullet or a small shell fragment, a collodion or cleol sticker is sufficient. Bleeding from intercostal arteries or a. mammaria interna requires ligation of these vessels.
Moderate hemothorax (up to the level of the middle of the scapula) does not require immediate intervention. In case of very abundant and especially progressive accumulation of blood in the pleural cavity (above the level of the middle of the scapula), excess blood (200-500 ml) is slowly sucked out to relieve life-threatening excessive intrapleural pressure.
Only in the case of a very rapid increase in hemothorax, in order to stop life-threatening bleeding, they resort to a wide opening of the pleural cavity to treat the lung wound and ligate the bleeding pulmonary vessels. The pleural cavity is opened under local anesthesia. Before the operation, a vagosympathetic blockade is performed. This prevents life-threatening bronchopulmonary shock.
Vago-sympathetic blockade is carried out according to Vishnevsky, injecting 30-60 ml of 0.25-0.5% novocaine solution into the deep cervical tissue through a needle inserted behind the sternocleidomastial muscle in the middle of its length.
It is rare to find a bleeding vessel in the lung. Then you have to limit yourself to applying a light hemostatic suture to the wound. After this, the lung is brought to the wound and fixed with a suture to the chest wall.
In case of open hemopneumothorax, complete (early or delayed) treatment of the wound of the chest wall and lung is fundamentally indicated, however, such intervention is justified only if the operator is fully qualified and the feasibility of the entire complex of measures taken for complex intrapleural operations.
Blood accumulated in the pleural cavity is removed as early as possible, since long-term presence of a large amount of blood in the pleural cavity contributes to the development of infection and the formation of too powerful inflammatory layers that prevent the expansion of the lung (B. E. Linberg, N. N. Elansky, etc.) . Typically, suction begins 1-2 days after injury. Suction is carried out slowly until the pleural cavity is completely emptied. If necessary, pumping is repeated after 2-3 days. After suction, penicillin is injected into the pleural cavity. If there is a large accumulation of blood clots in the pleural cavity that impede the removal of blood, a thoracotomy can be performed to remove the clots. The wound is sutured tightly. Minor hemothorax does not require active intervention.
Suppurating hemothorax is treated like empyema.
Closed pneumothorax goes away on its own and therefore does not require treatment. When treating open pneumothorax, they strive to transform it into an incomparably easier one - closed. As an initial temporary measure, they resort to applying an airtight bandage to the hole in the chest wall. One of the best dressings of this kind is a tile-shaped plaster, over which regular gauze is applied.
To permanently close the hole, surgical intervention is required, which is performed urgently (see below).
In case of suffocating valve pneumothorax, to provide first aid, a thick short needle (a needle for blood transfusion) is inserted into the pleural cavity and secured with a bandage. Typically, either a short drainage tube is used, onto the free end of which the finger of a thin rubber glove with the end cut off is put on, or a long drainage tube, the end of which is immersed in a vessel containing a disinfectant liquid located below. If this is not enough, further removal of air is carried out by constant active suction using a system of two bottles (Fig. 81) or a water jet or electric pump.
Subcutaneous emphysema does not require special treatment. In cases of very large and widespread development of emphysema, in extreme cases, skin incisions are made. With mediastinal emphysema, to free the mediastinum from air, a deep incision above the jugular notch and opening of the pretracheal tissue, which is a continuation of the mediastinal tissue, are sometimes necessary.
In general, for wounds of the pleura and lungs with a narrow collapsed wound canal and a closed pleural cavity, therefore, for most peacetime wounds (stab and knife wounds), for narrow bullet wounds and wounds from small fragments of explosive shells in wartime, conservative treatment is indicated.
With wide wounds of the chest with an open pleural cavity, for example, with large-caliber or tangential bullet wounds, with wounds from large fragments of explosive shells, early surgical intervention is possible. The operation is performed under local anesthesia. The operation consists of active surgical treatment of the wound and layer-by-layer closure of the hole in the chest wall. To do this, use a pedicle muscle flap, a rib periosteum flap, suture a lung (pneumopexy) or diaphragm to the edges of the wound, mobilize the adjacent section of the chest, and resect the rib. A lung wound is rarely treated, usually only when there is threatening bleeding. The skin is not sewn up in a military situation.
The operation converts an open pneumothorax into a closed one, thereby restoring the normal breathing mechanism. This also prevents infection, since during surgery the wound is cleaned and bone fragments and foreign bodies (tissue fragments, shell fragments) are removed. The location of the fragments is determined by preliminary x-ray examination.
To weaken the effects of shock, as well as cough, which can cause secondary bleeding, morphine or pantopon is administered subcutaneously. In case of shock and acute anemia, the patient is given a saline solution, a 5% glucose solution subcutaneously or intravenously, or, better yet, a blood transfusion by drip. In cases of shock, a vagosympathetic blockade is also performed. To weaken the pleural infection, a drainage tube is inserted into the pleural cavity through a small hole made below the wound channel in the chest wall and constant active suction of the accumulating effusion is established. Patients with penetrating chest wounds require complete rest and hospitalization. The most comfortable position for this type of wounded is semi-sitting.
The degree of disability after injuries to the pleura and lungs depends on the complications that have developed and the remaining consequences from the organs of the chest cavity (adhesions, displacement of the heart and great vessels of the mediastinum, the presence of fistulas and deformations of the chest and the functional disorders caused by them). Most patients with such changes are classified as disabled people of the third group.
PREVENTION OF PNEUMOTHORAX DURING OPERATIONS
Respiratory distress during surgical pneumothorax can be sufficiently prevented. To do this, either a closed pneumothorax is first applied, or during the operation, air is gradually and fractionally introduced into the pleural cavity through a small hole in the pleura, or the lung is removed into the wound and fixed with sutures to the edges of the chest wall wound (pneumopexy). The experience of transpleural operations has shown that these precautions are not absolutely necessary.
ICD-10
S27.3 Other lung injuries
General information
Causes
Classification
- crushed lung
Symptoms of lung damage
Closed lung injuries
Open lung injuries
Radiation damage to the lungs
- a slight dry cough or shortness of breath on exertion is bothering you;
- I am bothered by a constant hacking cough, the relief of which requires the use of antitussive drugs; shortness of breath occurs with slight exertion;
- the patient is bothered by a debilitating cough that is not relieved by antitussive drugs, shortness of breath is pronounced at rest, the patient requires periodic oxygen support and the use of glucocorticosteroids;
- severe respiratory failure develops, requiring constant oxygen therapy or mechanical ventilation.
Diagnostics
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: review
– lung injuries accompanied by anatomical or functional disorders. Lung injuries vary in etiology, severity, clinical manifestations and consequences. Typical signs of lung injuries include severe chest pain, subcutaneous emphysema, shortness of breath, hemoptysis, pulmonary or intrapleural bleeding. Lung injuries are diagnosed using chest x-ray, tomography, bronchoscopy, pleural puncture, and diagnostic thoracoscopy. Tactics for eliminating lung damage vary from conservative measures (blockades, physiotherapy, exercise therapy) to surgical intervention (suturing the wound, lung resection, 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. The problem of diagnosis and treatment tactics for lung injuries remains complex and relevant for traumatology and thoracic surgery.
Classification of lung injuries
It is generally accepted to divide all lung injuries into closed (with the absence of a chest wall defect) and open (with the presence of a wound opening). The group of closed lung injuries includes:
- lung contusions (limited and extensive)
- lung ruptures (single, multiple; linear, patchwork, polygonal)
- crushed lung
Open lung injuries are accompanied by a violation of the integrity of the parietal, visceral pleura and chest. According to the type of wounding weapon, they are divided into stab and gunshot weapons. Lung injuries can occur with closed, open or valve pneumothorax, with hemothorax, with hemopneumothorax, with rupture of the trachea and bronchi, with or without mediastinal emphysema. Lung injuries may be accompanied by fractures of the ribs and other bones of the chest; be isolated or combined with injuries to the abdomen, head, limbs, and pelvis.
To assess the severity of damage in the lung, it is customary to distinguish safe, threatened and dangerous zones. 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 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.
In addition to traumatic injuries to the lungs, they can be damaged by physical factors, for example, ionizing radiation. Radiation damage to the lungs usually occurs in patients receiving radiation therapy for cancer of the esophagus, lungs, or 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 there is a strong blow or compression of the chest in the absence of damage to the visceral pleura. Depending on the strength of the mechanical impact, such injuries can occur with intrapulmonary hemorrhages of varying volumes, bronchial rupture and crushing of the lung.
Minor bruises often go unrecognized; more severe ones are accompanied by hemoptysis, pain when breathing, tachycardia, and shortness of breath. During examination, hematomas of the soft tissues of the chest wall are often detected. In the case of extensive hemorrhagic infiltration of the lung tissue or crushing of the lung, shock and respiratory distress syndrome occur. Complications of a lung contusion can include post-traumatic pneumonia, atelectasis, and air cysts of the lung. 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, during breathing, air enters and leaves the pleural cavity with a characteristic “squelching” sound.
Traumatic emphysema develops as a result of air infiltration of the peri-wound 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 high-pressure mechanical ventilation. This condition may be accompanied by the development of subcutaneous emphysema, pneumothorax, lung collapse, mediastinal emphysema, air embolism and a threat to the patient’s life.
The mechanism of volumatic trauma is based not on rupture, but on overstretching of the lung tissue, which entails an increase in the permeability of the alveolar-capillary membranes with the occurrence of non-cardiogenic pulmonary edema. Atelectotrauma is the result of impaired evacuation of bronchial secretions, as well as secondary inflammatory processes. Due to a decrease in the elastic properties of the lungs, on exhalation, the alveoli collapse, and on inhalation, they become unstuck. The consequences of such lung damage can be alveolitis, necrotizing bronchiolitis and other pneumopathy.
Biotrauma is lung damage caused by increased production of systemic inflammatory response factors. Biotrauma can occur with sepsis, disseminated intravascular coagulation syndrome, traumatic shock, prolonged compartment syndrome and other severe 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 can be early (up to 3 months from the start of radiation treatment) and late (after 3 months or 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, and 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 damage to the lung may be indicated by external signs of injury: 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 weakened 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 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 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: 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 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, 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 of the respiratory tract to remove sputum and blood, and breathing exercises are recommended. In order to prevent suppurative complications, antibiotic therapy is prescribed. Physiotherapeutic methods are used to quickly resolve ecchymoses and hematomas.
In 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 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.
Often, injuries and various types of injuries to the thoracic region mean fractured ribs; in addition, the most important organs of the human body (heart, lungs, main blood vessels) are injured. When providing first aid to the victim, do not forget to determine whether there are breathing problems that are extremely dangerous to human life. This is the consequence that is most typical for the type of injury under consideration.
Consequences
There are several of the most dangerous consequences of chest injuries:
- Pneumothorax (accumulation of a large amount of air in the pleural cavity).
- Hemothorax (blood entering the pleural cavity).
- Emphysema of the mediastinum (begins to put pressure on large veins).
- Traumatic suffocation.
- Heart bruise.
- Cardiac tamponade (accumulation of blood in the pericardium as a result of its damage by rib fragments).
Types of injury
Types of damage:
- thoracic injuries (injuries can be open or closed);
- lung damage;
- injuries that are more complex (this may be rupture of the bronchi or diaphragm, dysfunction of the heart muscle).
These types of chest wounds can be inflicted with a knife or other weapon. Knife wounds often occur during fights and various domestic quarrels; puncture wounds can also occur due to negligence and during road accidents, emergencies and various natural and man-made disasters.
Injuries received by a person from firearms mainly occur during military operations, demonstrations, pickets, as well as during fights, shootings and quarrels. These wounds can be inflicted on the human body by a bullet, machine gun or machine gun fire, shrapnel or shot. And also during the explosion of mines, grenades and the use of explosive cluster shells.
Depending on the weapon used, they are divided into through, blind and tangential wounds. The first wounds have two holes - into which the damaging object entered, and a second hole from which this object came out. The second type of wound has only an entrance hole and no exit hole.
Characteristics of wounds
Injuries to the chest can be inflicted tangentially, then only soft tissue is damaged. A penetrating injury may break the bones of the chest, disrupt the area around the lungs, and damage the lungs. As a result of a wound inflicted by a knife, the integrity of soft tissues is mainly destroyed and blood vessels are damaged, while the bones remain intact. If a wound is received after the use of any type of weapon, not only soft tissues and blood vessels are destroyed, but bones are broken, and the broken bones, under the force of the shot, subsequently break and tear the internal organs and bones of the chest.
Knife wounds
Wounds inflicted by sharp piercing and cutting objects are accompanied by the following damage to organs, soft tissues and blood vessels. In many cases, a penetrating injury causes damage to the lungs, causing air to enter or bleeding to occur.
The cause of bleeding may be ruptured internal intercostal and other arteries that are located in the chest. As a result of this bleeding, a person's respiratory function and heart function deteriorate. In the case where air has entered the lungs, but there is no bleeding, all necessary medical methods must be taken. After a few days, the air will be able to leave the lungs.
Wound in the heart area
In addition to soft tissues, arteries and blood vessels, the injury can affect both the lining of the heart and the organ itself. very serious, as it can lead to the stoppage of this organ, as a result of which the person dies.
Basically, as a result of injury to an organ such as the heart, the atrium or ventricles are damaged; in rare cases, only the lining of the organ is damaged. The wound is very dangerous due to the bleeding in the form of a fountain, and the blood fills nearby organs.
Gunshot wounds
With a gunshot wound to the chest, the damage is more serious, as it entails rupture of tissue, tendons, bones, blood vessels and arteries. In addition to the charging substance itself, which gets into the wound, pieces of clothing and other foreign objects are also involved in it. With such a wound, in addition to the organs located in the chest, organs located in the abdominal region of the human body may also be damaged.
The location of the wound depends on the type of weapon used, the angle and distance from which the shot is fired. If the shot is fired from above, the bullet can enter the stomach through the respiratory tract. Depending on the power and caliber of bullets or shells, the liver, kidneys and other internal organs may also be damaged in the body.
Since breathing is impaired, the person feels unwell due to lack of oxygen in the blood. In addition, there is pain and irregular heartbeat. Blood emerges from the wound, as if filled with oxygen, in the form of foam. This means that the lungs are damaged, and the wounded person may also have blood in his saliva. Or bleeding from the mouth and at the same time from the wound. In case of a heart injury, a person has a discolored complexion and sweating increases on the body. People with this type of injury are in shock and are often admitted to the hospital unconscious. When checking your pulse, the result is barely noticeable. In the case of a bullet wound, blood pressure is greatly reduced.
Visually, if the heart is damaged, you can see an enlarged area on the chest in the area of the heart. If during a shot a bullet hits the liver, blood vessels or spleen, blood from these organs fills all the empty space and all organs inside the abdominal part of the body.
Symptoms
The chest, despite its rigid structure, is more often susceptible to trauma than any other part of the bone skeleton. A careless fall, a sharp blow, an illness or an emergency situation are quite capable of disrupting the integrity of the costal arch and sternum, leading to multiple problems with the respiratory and cardiovascular systems.
In order to diagnose the onset of serious failures, you need to know the symptoms of damage to the walls of the sternum:
- Pain that occurs every time you take a deep breath or exhale.
- The cough is chesty and very strong, with a whistling sound.
- Hemorrhage. If there is internal bleeding and inflammation of the internal organs, the cough is quickly supplemented by sputum mixed with blood.
- Deformation of the bone corset. If there was a fracture of the vaults.
- The development of pneumothorax - that is, excessive accumulation of air in the pleural cavity. Its signs are gurgling, whistling, hoarse tones when inhaling or exhaling. The main danger of this condition is the development of acute respiratory failure, asphyxia, and atony.
- Increase in body temperature to 38-39 degrees.
- Fever.
- Pulmonary edema. It is manifested by the appearance of white foam near the mouth in combination with impaired respiratory function, rapid heartbeat, a decrease or sharp increase in blood pressure, dizziness, weakness, and nausea.
First aid
It turns out that she is both on the spot and urgently at the nearest medical facility. First aid for a penetrating chest injury must be provided on the spot; if this is not done, medical assistance will be useless. This is the case when the body does not receive the required amount of oxygen. You urgently need to apply a cotton or gauze swab to the wound site, lubricating it with something greasy so that air does not get into the wound. Then you need to put a piece of polyethylene and a bandage on top.
For any type of injury, the patient must be urgently taken to the nearest medical facility.
Saving a life
First aid for a penetrating chest injury is to give the patient pain medication, as such injuries are quite painful. You can use metamizole sodium, ketorolac, tramadol in a dosage of 1-2 ml. And only medical workers in exceptional cases can give the victim a narcotic analgesic, for example a 1% solution of promedol. You also need to find something to treat the open wound with (hydrogen peroxide, iodine, brilliant green).
When a rib is fractured, the first thing to do is to apply a fixative, airtight bandage. If there are wounds, they must be treated, then cellophane is applied to the damaged area and only after that a fixing bandage is applied.
In case of heart contusion, accompanied by pain in the chest, low blood pressure and rapid heartbeat, medications are used to block the pain. As a rule, they are administered intravenously. Transportation of victims is possible only in a supine position with the upper body slightly elevated on a stretcher. In case of cardiac tamponade, transportation is carried out in a semi-sitting position using a stretcher. Without exception, all victims with chest injuries require urgent medical intervention. To do this, the patient is taken to the nearest surgical department, where doctors stop the bleeding and also use pain-relieving drugs and drugs to support heart function. Additionally, oxygen inhalations are used.
In case of cardiac tamponade, it is necessary to perform a pericardial puncture. Blood begins to flow continuously from the needle that pierced the pericardium. It is not removed until the patient is taken to the hospital, where doctors completely stop the bleeding. Also, during development, the doctor pierces the pleural cavity with a needle, after which he removes the air and blood accumulated there.
How to transport with a chest injury?
Transportation of the victim should be carried out, observing certain rules regarding the position in which he is located. Thus, the attendant must pay special attention to the position in which the wounded person is transported. Help should be given to bring him into a semi-sitting position with his knees bent. Having brought the victim into this position, it is necessary to place a cushion under him. Transportation must also be carried out in accordance with the following principles:
- efficiency;
- safety - it is necessary to ensure the patency of the victim’s airways, ensure gas exchange, as well as access to the respiratory tract;
- gentle attitude - it is not allowed to cause pain to a wounded person by failing to comply with transportation conditions, as this can lead to a state of shock.
The likelihood of saving the life of a wounded person directly depends on the success of the transportation, in particular, on the position occupied. Thus, compliance with the principles of transportation is one of the most important points in delivering to the chest area.
Treatment
Necessary primary medical care is to find something to treat the open wound, apply a bandage with a thick layer of sterile cotton wool, covered with a bandage, the edges should be several centimeters larger than the diameter of the injury. Stopping the flow of air into the tissues using a special patch will also help.
Before transporting the wounded, painkillers should be administered:
- morphine;
- pantopon, etc.
For bullet wounds, shattered parts or severe bruises should be removed surgically. This will help prevent sepsis and further tissue decay.
Treatment of bruises
In case of severe contusion of the chest, it is necessary to provide the patient with free access to oxygen and introduce an anesthetic blockade. Regardless of the type of chest injury, an x-ray is required to fully understand the extent of the damage.
Only after this is further treatment prescribed and a decision made as to whether surgical intervention is necessary. With a mechanical concussion of the chest, the victim goes into shock and has problems with independent breathing. In this case, it is necessary to organize the supply of air artificially.
Treatment of open wounds
In case of receiving open, lacerated injuries, it is necessary to stop the bleeding. Also, with injuries of this nature, it is impossible to do without suturing. If a rib is fractured, the victim’s movements should be limited until the ambulance arrives, as the bone can touch the heart, blood vessels or lungs, which will lead to more serious consequences, for example, hemorrhage. In the hospital, the ribs will be fixed in the correct position using a special corset. X-rays should not be neglected, as they can help identify the presence of fragments that need to be removed surgically. During the healing process (from 4 to 7 weeks), painkillers are used, for example, Novocain.
If the lungs are injured, the first step is to apply a tight bandage while exhaling. The victim should not be allowed to lose consciousness from loss of blood, as this can even lead to death. Next, the wounded person requires artificial respiration, taking measures to treat soft tissues with antiseptic agents to prevent infection, and suturing. Later, when the lungs are injured, regular dressings are first necessary to avoid the appearance of purulent wounds.
If the lungs are injured, 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.
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Such damage occurs due to fractured ribs and a simultaneous wound to the chest area. The situation is dangerous because severe bleeding and valvular or open pneumothorax occurs.
These symptoms are dangerous for the life support of the victim.
They will cause complications that will require urgent surgical intervention.
In case of a bullet wound to the lungs, when the victim has a closed chest injury, 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 closed pneumothorax, a puncture of the pleural cavity is performed. The procedure must be done when the mediastinum is displaced. Then air is aspirated 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 quickly cover the wounded area with a sealing bandage. A large gauze napkin folded many times is placed on top of it. 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 performing a vagosympathetic blockade according to Vishnevsky on the side that was injured will be effective.
Penetrating trauma
Symptoms of penetrating - bleeding from a wound on the chest, characteristically the formation of bubbles - air passes through the wound.
If the lungs are injured, the first thing you need to do is:
- First, you should make sure that there is no foreign object in the wound.
- Then you need to press your palm against the damaged area to limit the flow of air.
- If the victim has a through wound, the exit and entrance holes to the wound should be closed.
- Then you should cover the damaged area with material that allows air to pass through and secure it with a bandage or plaster.
- The patient should be placed in a semi-sitting position.
- It is necessary to apply something cold to the wound site, but first apply a pad.
- If there is a foreign body due to a stab wound to the lung, then you need to fix it with a roller made from scrap materials. You can secure it with a cloth or adhesive tape.
- 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.
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Closed wounds
A closed type of chest injury is characterized by a fracture of the chest bones. A closed heart injury is typical; there is 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 represents an injury to the rib cage. The organs in the chest are injured, but the skin remains intact.
Injuries often result from one or more blunt force injuries or surfaces resulting from a traffic accident. Often the chest is injured when they fall from a height, during a beating, a sharp simultaneous or numerous short-term or long-term squeezing of the patient in a crowd of people or rubble.
Closed form
- Promedol or analgin should be administered intramuscularly.
- Inhalation anesthesia with nitrous oxide and oxygen.
- Oxygen therapy for pain relief.
- You can use a circular bandage made from a plaster or an immobilizing bandage. They must be used when deformations of the rib frame are not visible.
- 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.
- Any medications for the heart are effective. Antishock agents can be used.
- After assistance has been provided, the patient should be taken to a medical facility.
- The patient must be transported on his back or on a stretcher. The upper half of the body should be raised. You can take the victim 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, different degrees of severity are distinguished. It is not easy to see a small, closed, minor chest wound.
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 damage is a consequence of an impact on a hard surface, compression, or exposure to a blast wave.
The most common circumstances in which people receive these injuries are road traffic accidents, unfortunate falls on the chest or back, blows to the chest with blunt objects, and falling under rubble as a result of collapses.
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 damage to the lung tissue topographically correspond to the irradiation fields used.
The cause of damage will be diseases accompanied by rupture of weakened lung tissue during coughing or physical effort. Sometimes the traumatic agent is foreign bodies of the bronchi, which can cause perforation of the bronchial wall.
Another type of injury worth mentioning is ventilator-induced lung injury, which occurs in ventilated patients. 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.
Physical data vary depending on the type of injury; weakening of breathing on the side of the affected lung is more often determined.
To correctly assess the nature of the damage, chest radiography in 2 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, and a foreign body.
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.
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